Cedar Creek Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bandera, Texas.
- Location
- 159 Montague Ave, Bandera, Texas 78003
- CMS Provider Number
- 675929
- Inspections on file
- 24
- Latest survey
- May 8, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Cedar Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Insulin Storage and Labeling Deficiency: The short hall med cart contained multiple insulin items that were not properly dated, including an open Lantus vial, an unopened Novolin vial, a Lantus pen, and a Novolog pen. The ADON said insulin containers should be dated for 28 days when removed from refrigeration and opened, but she was unsure when the items were taken out. The DON also confirmed insulin should be labeled with the expiration date when removed from the refrigerator, and the facility policy required pens to be dated when placed into use.
A resident with dementia/TBI and fluctuating cognition repeatedly told staff she wanted to go home with a family member, but the facility relied on an invalid MPOA/Responsible Party arrangement. The chart did not contain a valid resident-signed MPOA notarized for the named agent, and staff interviews showed they knew the resident could express her wishes yet did not document action to honor her discharge preference.
A resident with dementia, TBI, and prior severe cognitive impairment later became able to clearly express that she wanted to go home with Family Member D, but the care plan did not show updated discharge goals once she stabilized. Staff across nursing, Social Services, Activities, and administration knew she repeatedly voiced this preference, yet the chart did not show action to support her discharge wishes. The record also showed confusion about an MPOA that was not signed by the resident and no physician certification that she lacked competence to make her own health care decisions.
A resident with documented major depressive disorder, schizoaffective disorder, and a history of schizophrenia and bipolar disorder was incorrectly coded as having no MI on the PASARR PL 1 Screening. The chart also included psychiatric notes describing delusions, hallucinations, depression, and prior suicidal ideation, along with an antipsychotic order for schizoaffective disorder. During survey, the ADON described the resident as depressed and paranoid, and the MDS Coordinator acknowledged the PL 1 was inaccurate.
Incomplete and inaccurate resident clinical records: The facility’s EMR did not accurately reflect one resident’s active psych diagnoses, with schizophrenia/bipolar history and schizoaffective disorder not carried through the MDS, care plan, diagnosis tab, or PL 1 screening. For another resident, the chart lacked a valid resident-signed MPOA and physician certification of incompetence, the admission agreement was signed by family and BOM only, and staff did not document the resident’s behaviors and statements despite noting she could express her needs and wanted to go home.
Three residents experienced failures in pharmaceutical services, including missed documentation of narcotic administration by nursing staff and improper handling of a punctured Lorazepam blister pack. Nurses admitted to missing documentation due to workload, and staff were unclear on procedures for wasting controlled substances, leading to discrepancies between narcotic counts and records.
Surveyors found that food temperatures were not consistently documented, containers of food lacked discard dates, an air conditioner vent in the kitchen was unclean, and raw proteins were stored above fully cooked foods in the freezer. The CDM and staff acknowledged these lapses, which were not in line with facility policy or FDA Food Code standards.
A registered nurse left a medication cart laptop unlocked and unattended, displaying confidential information about a resident while entering another room for a medication pass. Facility leadership confirmed that the laptop should have been locked to protect resident privacy, as required by HIPAA and facility policy.
A resident with moderate cognitive impairment and a history of dementia and cataracts was found to have prescribed eye drops left at bedside by an RN, allowing unsupervised access to the medication. There was no assessment or documentation authorizing self-administration, and facility policy requires medications to be administered only by licensed personnel. The DON and ADM were unaware of any self-administration assessment for the resident.
A resident with moderate cognitive impairment and multiple medical conditions had a personal refrigerator that was not consistently maintained at or below 41°F, and temperature documentation was incomplete for several days. The facility did not enforce its policy on safe food storage for items brought in by family or visitors.
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Residents complained about cold and flavorless food, with meals often being late and trays sitting in the hall for extended periods. During meal service observation, food items required reheating, and a test tray revealed cold green beans, lukewarm turkey, and overcooked tater tots. The Dietary Supervisor and Administrator acknowledged potential negative impacts on residents' quality of life.
The facility failed to provide suitable snacks to residents outside scheduled meal times, particularly at bedtime, affecting diabetic residents who did not receive snacks labeled for their needs. Interviews revealed confusion among staff about responsibility for maintaining the resident refrigerator, which contained outdated food items. The facility lacked a clear protocol for offering snacks, and there was no follow-up to ensure snacks were distributed, contributing to the deficiency.
The facility failed to follow professional standards for food service safety. During a meal service, the cook and dietary aide did not wash their hands between tasks, violating the hand washing policy. The cook also used bare hands to handle food, contrary to the no-glove policy. These actions could risk foodborne illness.
The facility failed to maintain an effective infection prevention and control program, with staff observed not sanitizing equipment or performing proper hand hygiene. An ADON used unsanitized equipment on multiple residents, while an LVN did not wash hands between glove changes during wound care. These practices were acknowledged as breaks in infection control, posing potential risks of infection transmission.
Two residents in a facility were administered insulin without proper privacy measures, as observed by surveyors. One resident was injected with insulin in full view from the hallway, while another had her blood sample taken and insulin administered with the door open and no privacy curtain used. Both residents were moderately cognitively impaired and had type 2 diabetes. The nursing staff acknowledged the oversight, and the DON emphasized the expectation of providing privacy during care.
A facility failed to implement a comprehensive care plan for a resident requiring oxygen therapy. Despite medical orders for specific oxygen use, the care plan lacked details on the amount, duration, and frequency of oxygen therapy. Observations showed the resident using oxygen at 3 liters per minute, which was not documented. Interviews with staff confirmed the care plan should have been updated to reflect the resident's needs.
A resident with severe cognitive impairment and mobility issues was not provided with a fall mat as ordered by the physician, posing a risk for falls. The fall mat was observed folded against the wall instead of being placed beside the bed. Staff interviews revealed confusion about responsibility for ensuring the mat's use, with the DON acknowledging the oversight.
A resident's oxygen nasal cannula was improperly stored and not replaced as needed, leading to a deficiency in respiratory care. The nasal cannula was found on the floor and in an open drawer, contrary to facility policy requiring it to be stored in a protective bag. Interviews with the ADON and DON confirmed the oversight, highlighting the importance of proper storage to prevent infections.
The facility failed to ensure proper storage of drugs and biologicals, with a resident found with a jar of mentholated ointment on their nightstand and a medication cart left unlocked and unattended. The DON confirmed that residents are not allowed to self-medicate and that medication carts should remain locked to prevent unauthorized access.
A facility failed to maintain complete medical records for a resident with severe cognitive impairment, as the guardianship paperwork had expired and no renewal was found. The resident, who requires total assistance with ADLs and has multiple diagnoses, was observed frequently yelling and was not interviewable. The administrator relied on the social services worker to update the paperwork, who confirmed it was her responsibility and planned to contact the guardian for the updated document.
The facility failed to maintain effective pest control in the kitchen, as a live roach was observed near the oven. Despite recent pest control treatment, heavy German Cockroach activity was noted, and recommended targeted service was not documented. The facility's pest control policy was not effectively implemented.
The facility failed to maintain a pest-free environment, with German cockroaches observed in various areas, including the kitchen, for about a year. Staff interviews confirmed sightings, but the pest control log lacked documentation of these incidents. The pest control service inspection reported heavy cockroach activity and recommended targeted treatment and structural repairs.
A resident with moderate cognitive impairment was reportedly left on the floor by a nurse after a fall, and staff members failed to report the incident to the administrator within the required timeframe. Staff assumed the DON would handle the situation, but the DON did not report it, believing the fall did not occur. The facility's policy for immediate reporting of suspected abuse or neglect was not followed.
The facility failed to provide scheduled showers for three residents due to staffing issues on the 2-10 PM shift. A resident with cerebral infarction and hemiplegia had to repeatedly request a shower, while two other residents did not receive showers for an entire month. Staff interviews confirmed the issue was due to inadequate staffing, and the facility's administrator was aware and working on hiring more staff.
The facility failed to maintain privacy and confidentiality for residents when an LVN entered two rooms without knocking and another LVN left a computer screen open in a hallway displaying a resident's personal information. These actions violated the facility's policies on resident privacy and confidentiality.
A facility failed to implement a comprehensive care plan for a resident with a left-hand contracture, lacking interventions to maintain or improve mobility. The resident, with a history of cerebral infarction and hemiplegia, did not receive necessary therapy or devices due to financial constraints and the absence of a restorative program. Staff interviews confirmed the lack of restorative aides and devices, and the care plan did not include measures to address the contracture, resulting in a deficiency.
A resident with a left-hand contracture did not receive appropriate care to maintain or improve mobility. Despite having a history of cerebral infarction and hemiplegia, the resident lacked devices or therapy for the contracture. The care plan did not address the contracture, and staff interviews revealed a lack of awareness and action. Financial constraints and the absence of a restorative program contributed to the deficiency.
A facility failed to create a comprehensive care plan for a resident with peripheral vascular disease and multiple wounds. The resident's baseline care plan did not address her specific medical needs, including wound care for her condition. Despite receiving treatment, the comprehensive care plan was not completed, and necessary interventions were not documented, as confirmed by staff interviews.
Insulin Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, including the expiration date for 1 of 2 medication carts reviewed for medication storage. During an observation and interview with the ADON, the short hall medication cart was found to contain a Novolog insulin pen dated [DATE], an open Lantus insulin vial that was undated, an unopened Novolin insulin vial in the manufacturer’s box that was undated, a Lantus insulin pen that was undated, and a Novolog insulin pen that was undated. The ADON stated that all insulin containers should be dated for 28 days when removed from the refrigerator and opened, and she was unsure when the five insulin containers had been removed from the refrigerator. The ADON said it was the nurse’s responsibility to maintain the contents of the carts and that the nurse responsible for the cart had left work early. She was unsure whether the date on the Novolog pen was the expiration date or the date the pen was opened. In an interview with the DON, she stated that all insulin containers should be labeled with the expiration date by the nurse as soon as they are removed from the refrigerator, and she was unsure why the cart contained inaccurately labeled insulin pens and vials. The facility policy titled Insulin Pen Use stated that once an insulin pen is taken out of cool storage, it can be used for up to 28 days and must be dated when placed into use.
Invalid MPOA and Unaddressed Resident Discharge Wishes
Penalty
Summary
The facility failed to ensure Resident #40’s right to formulate an advance directive and failed to verify that Family Member B had valid authority to act as Responsible Party. Resident #40 was admitted with diagnoses including traumatic subdural hemorrhage with loss of consciousness and Alzheimer’s disease with late onset. Her records also reflected severe cognitive impairment on a quarterly MDS, but multiple notes documented that she could express her needs and wants, was oriented at times, and told staff she wanted to go home with Family Member D. The admission agreement listed Family Member B as Responsible Party and indicated medical decisions, admission, care, and discharge decisions were authorized, but the record did not contain a valid MPOA signed by Resident #40 and acknowledged before a notary public. The MPOA in the chart showed the signature acknowledged before a notary was Family Member B’s, not Resident #40’s. The record also did not show physician certification that Resident #40 lacked competence to make health care decisions, and did not show documentation that Resident #40 authorized Family Member B as her legal guardian or agent. During the stay, staff documented that Resident #40 repeatedly stated she wanted to discharge home with Family Member D and that she did not like being at the facility. Interviews with CNA, Social Services, Activities, LVN, ADON, MDS Coordinator, DON, BOM, and the Administrator confirmed that staff were aware of her wishes and that she could verbalize them. The Administrator note described a dispute between Family Member B and Family Member D regarding discharge, law enforcement involvement, and discharge home with Family Member D at Resident #40’s request. The record did not show that Social Services, nursing leadership, or the Administrator took documented action to honor her discharge wishes after learning of them.
Discharge planning did not reflect resident’s expressed home discharge preference
Penalty
Summary
The facility failed to ensure an effective discharge planning process for a resident whose condition improved and who was able to express her discharge preference. Resident #40 had diagnoses including traumatic subdural hemorrhage with loss of consciousness, Alzheimer's disease with late onset, non-Alzheimer's dementia, and traumatic brain injury. Her quarterly MDS reflected severe cognitive impairment with a BIMS score of 06, but other records and staff interviews documented that she later became able to communicate her needs and wants, participate in activities, and state that she wanted to go home with Family Member D to her home in North Carolina. The resident's care plan identified that she was resistive to care because she wanted to go home with Family Member D, and the goal focused on cooperation with care. However, the care plan did not show discharge plans once she stabilized and could make her preferences known. Facility records and interviews showed that staff were aware she repeatedly expressed a desire to discharge home with Family Member D, and multiple staff members stated she could verbalize her wishes clearly and that her cognition improved over time. The Administrator note documented that Family Member D told the facility she could provide 24/7 care, while Family Member B, listed as MPOA and responsible party, did not agree with the discharge. The record also showed confusion about the validity of the MPOA and who could make discharge decisions. The MPOA document in the chart was not signed by Resident #40, and the physician record did not show certification that she lacked competence to make health care decisions for herself. Social Services, nursing leadership, and the Administrator all acknowledged that Resident #40 expressed a desire to return home with Family Member D, but the EMR did not show action by Social Services, charge nurses, ADON, DON, or the Administrator to assist with honoring those wishes. The resident was ultimately discharged home with Family Member D after law enforcement was contacted and the physician was notified.
Inaccurate PASARR Level 1 Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure accurate PASARR Level 1 screening for a resident with documented mental illness on admission. Resident #6’s record showed diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, and schizoaffective disorder. The admission MDS reflected intact cognition, no behavioral symptoms, and active depression with antipsychotic and antidepressant use, but the PL 1 Screening dated 03/31/2026 was coded “No” for Mental Illness even though the resident was documented as having a mental illness. The resident’s record also contained multiple references to schizophrenia, bipolar disorder, and schizoaffective disorder from hospital and psychiatric records. Psychiatry documentation described a history of schizoaffective disorder, depressive type, prior suicidal ideation and depression, and later noted delusions and hallucinations. An order summary showed Secuado transdermal patch prescribed for schizoaffective disorder. The care plan included psych services to evaluate and treat as needed, but did not document bipolar or schizoaffective disorder as active diagnoses. During survey, the resident was observed standing at his doorway, appropriately dressed and groomed, and he stated he did not want to go to activities because he felt “funky.” The ADON stated the resident gets depressed and is paranoid. The MDS Coordinator stated she was responsible for ensuring the PASRR Level 1 Screening was accurate when received and acknowledged that the resident’s PL 1 Screening was inaccurate and that a new PL 1 Screening and PASRR evaluation would need to be submitted.
Incomplete and inaccurate resident clinical records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the record contained diagnoses of major depressive disorder and schizoaffective disorder, while the admission MDS reflected depression and a history of schizophrenia and bipolar disorder that were not documented as active diagnoses. The care plan did not include bipolar disorder or schizoaffective disorder, the EMR diagnosis tab did not show bipolar disorder, the PL 1 Screening was coded No for Mental Illness despite documentation that the resident had a mental illness, and the EMR did not show submission of Form 1012. A psychiatry evaluation later documented a history of schizophrenia and bipolar disorder, described as schizoaffective disorder, depressive type, per hospital records and collateral review. For the second resident, the EMR did not contain a valid MPOA signed by the resident, and the admission agreement was signed only by the family member and the business office manager. The MPOA document in the record showed the signature acknowledged before a notary was that of the family member, not the resident. The EMR also did not contain physician certification that the resident lacked competence to make health care decisions, and it did not contain documentation signed by the resident authorizing the family member as legal guardian or agent under a medical power of attorney. Staff interviews confirmed that the resident could express needs and wants, and multiple staff members stated the MPOA was not valid because it was not signed by the resident. The record also did not include progress notes documenting the resident’s behaviors and statements while at the facility. An administrator note documented a discharge dispute involving the resident, the family member, and another family member, including the resident insisting on going home and law enforcement being called. Interviews with the Activities Director, LVN, ADON, MDS Coordinator, BOM, and Administrator reflected that the resident participated in activities, verbalized needs and wants, and discussed wanting to return home, but staff did not recall whether these statements were documented in the EMR. The facility policy stated that documentation must be complete, accurate, timely, and properly signed, and that active diagnoses and required forms should be placed in the clinical record.
Failure to Ensure Accurate Documentation and Handling of Controlled Substances
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for three of eight residents reviewed. For one resident with chronic pain and moderate cognitive impairment, a registered nurse administered Hydrocodone-Acetaminophen as ordered but did not document the administration on the resident's narcotic sheet. This discrepancy was identified during shift change when the narcotic count did not match the number of medications in the cart. The nurse admitted that documentation was sometimes missed due to being busy, but confirmed the medication was given. Another resident with chronic pain, cancer, and moderate cognitive impairment had Tramadol administered by an LVN, but the administration was not documented in the Medication Administration Record (MAR) on two occasions, despite being recorded on the narcotic sheet. The LVN acknowledged forgetting to document in the MAR due to workload and recognized the importance of accurate documentation to track medication administration and prevent errors. A third resident with severe cognitive impairment and anxiety had a blister pack of Lorazepam punctured, but instead of wasting the dose as required, the pack was taped shut. Staff were unsure of the correct procedure, but another nurse clarified that punctured narcotic blister packs should be destroyed and witnessed by two nurses. The facility's policies required immediate removal and destruction of compromised medications and proper documentation of all administered and wasted controlled substances.
Deficiencies in Food Storage, Preparation, and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, specifically related to food storage, preparation, and documentation. There were several instances where food temperatures were not documented for breakfast, lunch, and dinner over multiple days, as required by facility policy. The Certified Dietary Manager (CDM) acknowledged that it was the cook's responsibility to record these temperatures, but he was overseeing the process and was unaware that the documentation was incomplete. Additionally, containers of jalapeno peppers, ketchup, and tartar sauce in the refrigerator were found without discard dates, contrary to professional standards and FDA Food Code requirements. Further observations revealed that the air conditioner vent in the kitchen, located above closed cereal containers, had visible black substances on it and had not been cleaned. The CDM was unsure who was responsible for cleaning the vent but agreed it needed attention. In the freezer, raw chicken was stored above pizza dough and cookie dough, which is not compliant with food safety standards that require raw proteins to be stored below fully cooked foods to prevent cross-contamination. Staff interviews confirmed awareness of these standards, but lapses in practice were evident. Record reviews showed that the facility's policies required regular cleaning of the dietary department and equipment, as well as daily documentation of food temperatures before meal service. However, the food storage policy did not specify the need for dating food products with expiration or discard dates, as outlined in the FDA Food Code. Despite these deficiencies, the Director of Nursing (DON) reported no pattern of gastrointestinal issues among residents in the past six months, based on infection control surveillance records.
Unsecured Laptop Screen Exposes Resident Information
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a laptop on a medication cart unlocked and unsupervised, displaying confidential resident information, while entering a resident's room during a medication pass. This incident was observed and confirmed through interviews with facility administration, who acknowledged that the laptop should have been locked to protect resident privacy in accordance with HIPAA requirements. The facility's policy on resident rights also states that residents have the right to secure and confidential personal and medical records. The failure to lock the computer screen allowed for the possibility that resident information could be seen or accessed by unauthorized individuals passing by. The report does not specify the identity or medical history of the resident whose information was exposed, nor does it provide details about their condition at the time of the incident.
Medication Storage and Administration Protocol Not Followed
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a resident's prescribed eye drop medication at the bedside, allowing the resident to access and potentially self-administer the medication unsupervised. The resident, a male with dementia and a cataract diagnosis, had a moderate cognitive impairment as indicated by a BIMS score of 11 out of 15. The medication, Prolensa Ophthalmic Solution, was ordered to be administered once daily for cataract surgery. During an interview and observation, the RN acknowledged that the medication should not have been left at the bedside, even though the resident might be capable of self-administration. Further investigation revealed that there was no documentation or assessment indicating that the resident was authorized or capable of self-administering his medications. The Director of Nursing (DON) and Administrator were unaware of any such assessment or care plan. Facility policy requires that only licensed or legally authorized personnel administer medications and that medications are not left with residents unless proper assessment and documentation are in place. This lapse in medication storage and administration protocol led to the cited deficiency.
Failure to Maintain and Document Safe Refrigerator Temperatures for Resident Food Storage
Penalty
Summary
The facility failed to implement and enforce a policy regarding the use and storage of foods brought in by family and other visitors for residents. Specifically, the facility did not ensure that a resident's personal refrigerator maintained a temperature at or below 41 degrees Fahrenheit, as required by facility policy. Temperature logs showed that for several days, the refrigerator was above the recommended temperature, and for a subsequent period, temperatures were not documented at all. This lapse was identified through observation, interview, and record review. The resident involved was an older adult with a history of constipation, protein-calorie malnutrition, and nausea, and had moderate cognitive impairment as indicated by a BIMS score of 12 out of 15. Despite the resident reporting no illness from consuming food stored in her refrigerator, the facility's failure to monitor and document refrigerator temperatures as per policy constituted a deficiency in ensuring safe and sanitary food storage for residents.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. During an initial tour, two residents complained about the food being cold and lacking flavor, with one resident noting that the food was not of restaurant quality. Confidential interviews during a Resident Meeting confirmed that the food was frequently cold and lacked taste, with several residents noting that meals were often late and trays sat on the hall in carts for over 15 minutes before being handed out. The carts used for delivering trays to the dining room were open type, providing no insulation other than dome covers. During an observation of meal service, the cook had to reheat several items to bring them up to the required temperature on the steam table. The last cart went out over an hour later than the scheduled meal service time, and the Administrator was observed checking each plate, allowing heat to escape. A test tray delivered to the state survey room revealed that the green beans were cold, the turkey was lukewarm, and the tater tots were overcooked and hard. The Dietary Supervisor and Administrator acknowledged that residents could experience weight loss and a diminished quality of life if food was served cold and not palatable.
Failure to Provide Snacks and Maintain Refrigerator
Penalty
Summary
The facility failed to ensure that residents received suitable and nourishing meals and snacks outside of scheduled meal service times, particularly at bedtime. During a Resident Meeting, it was revealed that snacks were not offered at bedtime unless specifically requested by the residents. Three out of seven residents, who were diabetic, reported not receiving any snacks labeled with their names, indicating a lack of attention to their dietary needs. This oversight could potentially affect all residents, especially those with specific dietary requirements such as diabetics, by increasing the risk of unplanned weight loss and medication side effects. Interviews with various staff members, including the Dietary Supervisor (DS), Maintenance Director, and Administrator, highlighted a lack of clarity regarding responsibility for maintaining the resident refrigerator and distributing snacks. The DS showed the surveyor a refrigerator containing outdated and undated food items, and there was confusion among staff about who was responsible for cleaning and maintaining the refrigerator. The DS assumed that nursing staff were responsible for distributing snacks, while the Maintenance Director and Administrator believed that housekeeping should maintain the refrigerator. Further observations and interviews revealed that the facility did not have a clear protocol for offering snacks to residents, particularly those with dietary needs such as diabetics. The DS mentioned that a list of diabetic residents was requested, and snacks were prepared for them, but there was no follow-up to ensure these snacks were distributed. The facility lacked a policy for snacks, and the existing policy for cleaning the refrigerator was outdated, contributing to the deficiency in providing adequate nutrition and care to the residents.
Failure to Follow Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a lunch meal service. The cook did not wash his hands between tasks, such as taking food temperatures, writing notes, flipping through pages, gathering serving utensils, and washing thermometers. Similarly, the evening cook, who was serving as a dietary aide, was observed preparing dessert items and covering bowls with plastic wrap without washing her hands. These actions were in violation of the facility's hand washing policy, which mandates frequent hand washing to prevent cross-contamination. Additionally, the cook was observed using his bare hands to place rolls on plates during meal service, contrary to the facility's no-glove policy on the steam table. The Dietary Department Glove Standard Protocol specifies that there should be no bare hand-to-food contact in the kitchen, and utensils like tongs should be used to handle ready-to-eat food items. The failure to follow these protocols could place residents at risk for foodborne illness, as the facility did not ensure proper hand hygiene and food handling practices.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and equipment sanitation. During observations, the Assistant Director of Nursing (ADON) was seen administering medications to residents without sanitizing the blood pressure cuff and pulse oximeter between uses. The ADON also failed to perform proper hand hygiene after administering medications to two residents, which was acknowledged as a break in infection control by the ADON during an interview. In another instance, a Licensed Vocational Nurse (LVN) did not perform proper hand hygiene before entering a resident's room and during wound care procedures. The LVN was observed changing gloves multiple times without washing or sanitizing hands in between, and used scissors that were not sanitized prior to use. The LVN admitted to not being trained about washing or sanitizing hands between glove changes and acknowledged the potential for cross-contamination due to these practices. The Director of Nursing (DON) confirmed the expectation for staff to perform proper hand hygiene between glove changes and highlighted the risks of improper hand hygiene, including the spread of bacteria and infection. Despite the facility's policies on hand hygiene and infection control, these practices were not followed, leading to potential risks of infection transmission among residents.
Failure to Ensure Privacy During Insulin Administration
Penalty
Summary
The facility failed to ensure privacy and dignity for two residents during insulin administration. Resident #11, a moderately cognitively impaired female with type 2 diabetes, was observed receiving an insulin injection without privacy measures in place. The Licensed Vocational Nurse (LVN) administering the injection did not close the bedroom door or pull the privacy curtain, leaving the resident exposed to view from the hallway. Despite the resident stating it did not bother her, the LVN acknowledged forgetting to provide privacy, recognizing it as a dignity issue. Similarly, Resident #27, also moderately cognitively impaired and diagnosed with type 2 diabetes, was administered insulin without adequate privacy. The LVN left the bedroom door open and did not use the privacy curtain while obtaining a blood sample and administering the insulin injection. Although the resident expressed that it did not bother her, the LVN admitted to not providing privacy, assuming it was acceptable since the resident did not have a roommate. The Director of Nursing (DON) stated that it was expected for nursing staff to provide privacy by at least pulling the privacy curtain and closing the door during care. The lack of privacy during these procedures was identified as an invasion of privacy, with the DON emphasizing the importance of maintaining residents' dignity in their living environment. A policy and procedure regarding privacy and dignity was requested but not provided at the time of the report's exit.
Failure to Implement Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included specific interventions for the use of oxygen therapy. The resident, a female with diagnoses including dementia, heart failure, pneumonia, and shortness of breath, was admitted and readmitted to the facility. Her medical records indicated the need for oxygen therapy, with specific orders to check oxygen saturation every shift and to use oxygen at 2 liters per minute as needed. However, the comprehensive care plan did not specify the amount, duration, or frequency of oxygen use, despite changes in the resident's orders dating back to December. Observations revealed that the resident was using oxygen at 3 liters per minute, which was not documented in the care plan. Interviews with the MDS Coordinator and the DON confirmed that the care plan should have been updated to reflect the resident's specific needs for oxygen therapy. The facility's policy on comprehensive care planning emphasized the need for measurable objectives and timeframes to meet residents' needs, which was not adhered to in this case.
Failure to Utilize Fall Mat as Ordered
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, the facility did not utilize a fall mat for a resident as per the physician's orders. The resident, a female with severe cognitive impairment and dependent on staff for bed mobility and transfers, was observed without the fall mat in place while in bed, contrary to the care plan and physician's orders. During observations, the fall mat was found folded and leaning against the wall at the foot of the bed, rather than being placed on the floor beside the bed as required. Staff interviews revealed confusion about who was responsible for ensuring the fall mat was in place, with the CNA and Hospice Aide both indicating that the mat was not in use when they entered the room. The Director of Nursing acknowledged that the fall mat should be on the floor when the resident is in bed to prevent injury from falls, and that it was the responsibility of the CNA, nursing staff, and ultimately the DON to ensure compliance with this safety measure.
Improper Storage and Handling of Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as observed during multiple instances. The resident's oxygen nasal cannula was not properly stored or protected when not in use, which is inconsistent with professional standards of practice and the facility's policy. Observations revealed that the nasal cannula was left on the floor and in an open drawer, rather than being stored in a protective bag. The tubing was also not replaced as needed, despite being visibly contaminated and dated several days prior. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the improper handling and storage of the oxygen equipment. The ADON acknowledged that the tubing should have been replaced and stored correctly, while the DON emphasized the importance of keeping the tubing clean to prevent infections. The facility's policy on oxygen administration requires that tubing be changed when contaminated and stored properly, which was not adhered to in this case.
Improper Storage of Drugs and Biologicals
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals, as evidenced by two specific incidents. In the first incident, a resident was found to have a jar of mentholated ointment on their nightstand, despite the facility's policy that residents are not allowed to self-medicate. The resident, who was moderately cognitively impaired and had a history of dementia and other health conditions, was observed with the ointment on multiple occasions. The Director of Nursing (DON) confirmed that no residents were permitted to have medications at their bedside due to the risk of inappropriate use or access by other residents, particularly those who wander. In the second incident, a medication cart on The Long Hall was found unlocked and unattended during a medication pass. The Licensed Vocational Nurse (LVN) acknowledged the oversight, noting that it posed a risk as any resident or unauthorized person could access the medications. The DON reiterated the expectation that medication carts should remain locked and secured to prevent unauthorized access. The facility's policy on medication storage emphasizes that medications should be stored safely and securely, accessible only to authorized personnel.
Incomplete Medical Records Due to Expired Guardianship
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the current status of the resident's guardianship paperwork. The resident, a male with severe cognitive impairment and multiple diagnoses including unspecified dementia and major depressive disorder, was admitted to the facility with a guardian as the only emergency contact and responsible party. The guardianship paperwork on file had expired, and no renewal was found in the medical record, which could affect the validity of consent for treatment. During the survey, the resident was observed to be frequently yelling and was not interviewable due to cognitive issues. The facility's administrator acknowledged the importance of keeping guardianship paperwork up to date and indicated reliance on the social services worker for this task. The social services worker confirmed it was her responsibility to maintain current guardianship paperwork and stated she would contact the guardian to obtain the updated document.
Ineffective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain effective pest control in the kitchen, as evidenced by the presence of a live roach observed crawling on the wall near the oven, which was next to the steam table. This incident was witnessed during an observation and interview with the Dietary Supervisor, who promptly removed the roach and informed the Administrator to contact the pest control company. Despite recent pest control treatment, the presence of roaches indicates that the measures taken were insufficient. A review of the pest control log revealed that the pest control company had visited the facility on a previous date to address roaches and other pests. The report from this visit noted heavy German Cockroach activity in the kitchen and recommended an after-hours targeted service of kitchen equipment. However, there was no documentation indicating that this recommended service was carried out. The facility's policy for insect and rodent control, dated 2012, outlines procedures for maintaining an insect and vermin-free environment, but the observed deficiency suggests these procedures were not effectively implemented.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a resident environment free of pests and rodents, as evidenced by the presence of German cockroaches. Interviews with staff and residents revealed that cockroaches had been observed in various parts of the facility, including the kitchen, for about a year. Despite the presence of pests, the facility's grievance and pest control logs did not reflect any reports of cockroaches, indicating a lack of documentation and communication regarding the issue. The facility's policy on insect and rodent control, which requires maintaining an effective pest control program, was not effectively implemented. Interviews with staff, including CNAs, an LVN, and the DON, confirmed sightings of live roaches and previous incidents involving mice. The pest control service inspection report noted heavy German cockroach activity in the kitchen and recommended after-hours targeted service and structural repairs to prevent pest access. The ADM acknowledged that staff were expected to document pest sightings in the pest control log, but this was not consistently done, preventing timely intervention by the maintenance director.
Failure to Report Alleged Neglect in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, as required by regulations. This deficiency was identified in the case of a resident who had moderate cognitive impairment and required assistance with mobility. The resident was reportedly left on the floor by a nurse after a fall, and staff members did not report this incident to the administrator within the mandated timeframe. Interviews with staff members revealed that they were aware of the incident where the nurse left the resident on the floor, but they assumed it would be handled by the Director of Nursing (DON). The staff members did not report the incident directly to the administrator, as they believed the DON would take the necessary steps. The DON, however, did not report the incident to the administrator, as she believed the fall did not occur and therefore no neglect took place. The administrator stated that he expected all allegations of abuse, neglect, or exploitation to be reported to him directly. However, the staff had been trained to report such incidents to the DON, which led to a breakdown in communication and reporting. The facility's policy required immediate verbal reporting of suspected abuse or neglect to the Abuse Preventionist or designee, but this protocol was not followed in this case.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents who are unable to perform activities of daily living received the necessary services to maintain grooming and personal hygiene. This deficiency was identified for three residents who were scheduled to receive showers on the evening shift of Monday, Wednesday, and Friday. However, due to staffing issues, these showers were not consistently provided. Specifically, on a Monday shift, only one CNA was available, which resulted in the showers not being completed for the residents. Resident #1, who has a history of cerebral infarction, hemiplegia, and requires extensive assistance with bathing, reported having to repeatedly ask staff for a shower. Despite eventually receiving a shower, the resident expressed frustration over the uncertainty of receiving necessary care. Resident #4, who requires supervision or touching assistance with bathing due to cognitive and physical impairments, did not receive a shower for the entire month of January 2025, as documented in the POC task records. Similarly, Resident #5, who has dementia and requires setup or cleanup assistance, also did not receive a shower for the same period. Interviews with staff revealed that the lack of adequate staffing on the 2-10 PM shift contributed to the failure to provide showers. A CNA working that shift confirmed the inability to complete resident baths, and an LVN acknowledged awareness of the issue, noting that it had been ongoing since December 2024. The facility's administrator was informed of the situation and was in the process of addressing staffing shortages. The facility's policy on bathing emphasizes the importance of regular showers for maintaining hygiene and comfort, yet this standard was not met due to the staffing challenges.
Privacy and Confidentiality Breach by LVNs
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as observed in two separate incidents involving Licensed Vocational Nurses (LVNs). In the first incident, LVN J was observed entering two residents' rooms without knocking, which was confirmed during an interview with LVN J, who acknowledged the oversight and expressed an intention to improve. This action violated the residents' right to personal privacy as outlined in the facility's policy. In the second incident, LVN Z left a computer screen open in a hallway, displaying a resident's personal information while people passed by. During an interview, LVN Z admitted to forgetting to turn off the monitor due to being preoccupied with checking residents' lunch trays. This oversight was a breach of the facility's policy on safeguarding resident confidentiality and personal privacy, which mandates that access to personal and medical records be limited to authorized personnel only.
Failure to Address Resident's Hand Contracture in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a left-hand contracture. The resident, who had a history of cerebral infarction, epilepsy, and hemiplegia, did not have interventions in place to maintain or improve mobility in the affected hand. Observations revealed that the resident's care plan lacked specific measures to address the contracture, such as the use of a device to prevent fingernails from digging into the skin. Interviews with staff, including a CNA and a PT, confirmed that the resident's left hand was contracted and that there were no restorative aides or devices available to assist with the condition. The PT mentioned that the resident did not have the finances for therapy, and the facility occasionally paid for therapy services. However, the resident had not received a splint or device for the left-hand contracture, and there was no restorative program in place due to the facility's financial constraints and the impact of COVID-19. The MDS coordinator acknowledged that the resident's care plan did not include restorative services, and the facility's policy on comprehensive care planning was not effectively implemented. The resident's financial situation and lack of insurance coverage were cited as reasons for the absence of therapy and restorative interventions. Despite having funds in a trust, the resident's care plan did not reflect necessary interventions to address the contracture, leading to a deficiency in meeting the resident's medical and physical needs.
Failure to Provide Appropriate Care for Resident's Hand Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited mobility, specifically regarding the management of a left-hand contracture. The resident, who had a history of cerebral infarction, epilepsy, and hemiplegia affecting the left side, was observed to have a left-hand contracture without any devices to maintain or improve mobility. Interviews with the resident and staff revealed that no interventions were in place to prevent the fingernails from digging into the skin, and there was no therapy or restorative program addressing the contracture. The resident's care plan did not include interventions for the left-hand contracture, despite the resident's condition being documented in various records. The facility's physical therapist confirmed that the resident had not received a splint or device for the contracture and that the facility lacked restorative aides. Financial constraints were cited as a reason for the lack of therapy, with the facility occasionally covering therapy costs due to the resident's limited insurance coverage. Interviews with staff, including CNAs and the MDS coordinator, indicated a lack of awareness and action regarding the resident's contracture. The facility had previously had a restorative program, but it was discontinued, and no current policies or interventions were in place to address the resident's needs. The absence of a comprehensive care plan for the contracture and the lack of restorative services contributed to the deficiency in care for the resident.
Failure to Develop Comprehensive Care Plan for Resident with Vascular Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with multiple medical conditions, including peripheral vascular disease and multiple wounds. The resident, an 84-year-old female, was admitted with diagnoses such as sepsis, type 2 diabetes with neuropathy, and peripheral vascular disease, particularly affecting her right foot. Despite these conditions, the baseline care plan only addressed fall prevention, wound care for lacerations and skin tears, and diabetes management, without specific interventions for the resident's peripheral vascular disease or wound care. The resident's medical records indicated severe peripheral artery disease and other complications, including a lower extremity ulcer with cellulitis and MRSA. The resident received treatment for arterial wounds as ordered by the physician, but the comprehensive care plan did not reflect these interventions. Interviews with staff, including the MDS nurse and the former DON, revealed that the comprehensive care plan was not completed within the required timeframe, and the necessary interventions for the resident's condition were not documented. The absence of a comprehensive care plan was acknowledged by the facility's staff, including the administrator and the MDS nurse, who admitted that the plan was not developed as required. The failure to document and communicate the necessary interventions for the resident's peripheral vascular disease and wound care through a comprehensive care plan could have impacted the quality of care provided to the resident, as it did not capture the physician's orders or the resident's specific needs.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
