Cedar Manor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Angelo, Texas.
- Location
- 1915 Greenwood St, San Angelo, Texas 76901
- CMS Provider Number
- 676068
- Inspections on file
- 38
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Cedar Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility’s activities program was directed by an Activity Director (AD) who did not meet required qualifications. The AD had been in the role for several months without being enrolled in an activities director course and was not certified, despite the facility’s job description requiring a certified AD with appropriate state-required credentials. Interviews with the AD and the Administrator, along with personnel record review, confirmed that the AD lacked the necessary certification and training, potentially affecting the provision of individualized activities for residents.
Surveyors found that kitchen sanitation and staff hair restraint practices did not meet professional standards. Bottom shelves holding dishes, pots, and pans were soiled with food crumbs and dust, the stove and oven had grease and dried food buildup, the vent hood was dusty, and pantry shelving and a freezer bottom shelf were dirty with crumbs and debris. During food preparation, the Dietary Manager’s hair net did not fully cover her hair, and another dietary staff member had hair protruding from the back of a hair net. The Dietary Manager and Administrator acknowledged expectations for proper hair coverage and routine cleaning, and facility policy required effective hair restraints and cleaning/sanitizing of kitchenware and food-contact items after each meal.
Surveyors identified that the facility failed to properly implement its infection prevention and control program when an LVN did not disinfect a glucometer between blood glucose testing for a resident and reported using tissue and hand sanitizer instead of the required germicidal/bleach wipes, contrary to facility policy and DON expectations. In a separate observation, two CNAs provided incontinent and urinary catheter care to a resident with a neurogenic bladder and an indwelling catheter who was on Enhanced Barrier Precautions, but they wore only gloves and omitted gowns despite posted EBP signage and care plan instructions requiring gown and glove use for high-contact care. Both CNAs later acknowledged they had forgotten to wear gowns, and leadership confirmed staff were trained and expected to use appropriate PPE and that failure to do so could lead to infections and cross contamination.
Surveyors found that all reviewed dual-occupancy rooms used a single ceiling-to-floor curtain that divided the room but did not extend around each bed or fully cover the area near the door, resulting in a lack of full visual privacy for residents. The DON acknowledged being unaware that the curtains did not provide full visual privacy and noted that residents could be exposed during care if the door was not closed. The Administrator also recognized the possibility of resident exposure during care and reported that the facility had no policy addressing full visual privacy curtains.
The facility failed to maintain a safe and sanitary environment when an industrial-sized garbage dumpster at the back of the building was observed placed directly on a dirt surface instead of on a concrete slab. During the survey, it was also determined that the facility lacked a policy addressing dumpster placement and management, contributing to this environmental sanitation deficiency.
Numerous missing and damaged ceiling tiles in Hall 3 were left unrepaired after air conditioning work, exposing electrical wires and air ducting. A resident expressed dissatisfaction with the prolonged disrepair, and both the Maintenance Director and Administrator acknowledged the need for replacement.
The facility did not post up-to-date nurse staffing information in a prominent location for 12 consecutive days. The ADON, responsible for posting, stated she had been busy with other duties and forgot to update the information, and the Administrator was unaware the postings were not current. Facility policy requires daily posting of nurse staffing details for residents and visitors.
A resident with multiple health conditions and a high fall risk experienced an unwitnessed fall after attempting to toilet herself. Despite a completed fall risk assessment and increased monitoring initiated by staff, the care plan was not updated to include new interventions. Staff relied on verbal communication rather than reviewing or revising the care plan, and the DON was unaware of the lack of updates.
A facility failed to maintain an effective infection control program when the DON and an RN did not follow Enhanced Barrier Precautions (EBP) during wound care for a resident with a history of acute osteomyelitis and other health conditions. Despite the resident's care plan requiring EBP, both staff members neglected to wear gowns, citing busyness and oversight. This failure to adhere to the facility's EBP policy could lead to cross-contamination and infection.
The facility failed to maintain resident dignity by serving meals on trays in a manner deemed institutional-like and allowed staff to use personal cell phones during care, making residents feel ignored. Observations and resident interviews confirmed these practices, which violated the facility's policy on personal communication devices.
A facility failed to maintain an effective Infection Prevention and Control Program during wound care for a resident with a chronic ulcer. RN B did not adhere to proper hand hygiene protocols, failing to change gloves and perform hand hygiene at critical points. The nurse also did not clean the bedside table or use a barrier before placing supplies, and did not clean the wound care spray bottle after use. The DON and Administrator acknowledged the importance of proper technique, but the facility's policy was not followed.
The facility failed to prepare 33 resident rooms in B Building for occupancy, as they were used for storage and required cleaning and repairs. These rooms, identified as Title 18 Medicare-Only and dually certified beds, had not been used since 2020. Interviews revealed that the rooms could not be made livable quickly, and the corporate plan to remodel the building was not prioritized due to low census. The facility lacked a policy on bed classification, and the corporation did not want to declassify the rooms due to recertification costs.
Unqualified Activity Director Leading the Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional, as the current Activity Director (AD) did not meet the required qualifications. During an interview, the AD reported she had been working in the role since April 2025 and was not registered for an activities director course. She stated that a previous administration had told her they would assist her with getting registered for an AD course, but after that administration left, she did not get enrolled. Record review confirmed the AD was neither enrolled in an activity course nor certified as an AD. The facility’s job description for the Activity Director, dated 2014, specified that the position required a high school graduate with certification where required by state regulations and that the individual must be a certified Activity Director. The report stated this failure could place residents at risk for reduced quality of life due to lack of individualized activities that matched their skills, abilities, and interests/preferences. The Administrator acknowledged in an interview that the AD was not yet enrolled in the required AD course and confirmed they were working on getting her enrolled, further supporting that the AD did not currently meet the stated qualification requirements.
Food Service Sanitation and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper food storage, preparation, distribution, and service practices that did not meet professional standards. During an initial kitchen tour, they observed that bottom shelves throughout the kitchen, including those holding dishes, pots, and pans, were soiled with food crumbs and dust. The stove and oven were soiled with grease, food crumbs, and dried food, and the vent hood was covered with a layer of dust. In the pantry, the bottom shelf of the freezer was soiled with food crumbs and frozen foods, and a shelf with plastic covering was noted to have a layer of dust and food crumbs. These observations were reviewed with the Dietary Manager, who acknowledged the presence of food crumbs, dirt, and dust on these surfaces. In a follow-up observation during food preparation, the Dietary Manager’s hair net covered only the bun or top part of her hair, and another dietary staff member had hair coming out of the back of her hair net. In an interview, the Dietary Manager stated that hair nets should cover all hair, explained that her hair net sometimes rolled up without her noticing, and admitted she had not noticed the other staff member’s hair hanging out of the hair net. The Administrator later stated that his expectation was for staff to wear hair nets correctly and for the kitchen, including the stove, oven, freezer, appliances, and vent hood, to be cleaned routinely. Review of the facility’s Infection Control policy showed that clean hair was required to be covered with an effective hair restraint and that all kitchenware and food contact items used in preparation or serving of food were to be cleaned and sanitized before use and cleaned after each meal preparation.
Failure to Disinfect Glucometer and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program related to glucometer disinfection and use of personal protective equipment (PPE) during care of a resident on Enhanced Barrier Precautions (EBP). During observation, an LVN obtained a fasting blood sugar from Resident #21 by taking a small blood sample from the resident’s finger and applying it to a test strip in a glucometer. After completing the blood sugar test, the LVN exited the room and placed the glucometer on the cart without sanitizing it. In interview, the LVN stated she used a tissue and hand sanitizer to sanitize the glucometer and reported she was unaware of what she was supposed to use to sanitize it. The DON stated that glucometers were supposed to be cleaned using bleach wipes, that nurses were trained upon hire and annually on proper disinfection of glucometers, and that the risk of not using the proper solution for sanitizing glucometers was passing on infections. Facility policy for glucometers required the meter to be cleaned with a germicidal and allowed to air dry between patient testings. The deficiency also involves failure to follow EBP requirements for a resident with an indwelling urinary catheter. Resident #3 was admitted with neuromuscular dysfunction of the bladder and muscle weakness and had an indwelling catheter for neurogenic bladder. The resident’s care plan documented that she was on EBP, with an expectation that there would be no signs and symptoms of urinary infection and no transmission of infection from or to the resident. The care plan specified that gloves and gown should be donned for high-contact activities including linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. The MDS assessment also indicated the presence of an indwelling catheter. During observation, two CNAs entered Resident #3’s room to perform incontinent care. Both staff washed their hands and put on gloves but did not don gowns despite an EBP posting outside the room. They removed the resident’s brief, cleansed the vaginal area and urinary catheter tubing with wet wipes, turned the resident to her side, cleansed the rectal area where a bowel movement was present, repositioned the urinary catheter on the bed, and applied a new brief. In interviews, both CNAs acknowledged that the EBP posting indicated they were supposed to use PPE such as gloves and a gown when providing personal care for a resident with a urinary catheter, stated they had forgotten to wear a gown, and agreed they should have worn a gown along with gloves. The ADON stated staff were expected to wear EBP when providing care for residents with a urinary catheter and that the CNAs had been trained and were aware they had to wear PPE but had forgotten. The DON and Administrator both stated that failure to wear PPE as indicated could lead to infections or cross contamination. The facility’s Enhanced Barrier Precautions policy stated that EBP is indicated for residents with wounds and/or indwelling medical devices, including urinary catheters, and involves targeted gown and glove use during high-contact resident care activities.
Failure to Provide Full Visual Privacy in Dual-Occupancy Rooms
Penalty
Summary
Surveyors identified that dual-occupancy rooms in the facility were not designed or equipped to assure full visual privacy for residents. Observation of rooms 301, 303, 306, 307, 309, and 310 showed each contained an A and B bed separated only by a single ceiling-to-floor curtain that divided the center of the room but stopped approximately 24 inches from the door, and the curtains did not extend around the entire beds to provide full coverage and privacy. These observations demonstrated that the rooms lacked ceiling-suspended curtains that extended around each bed to provide total visual privacy. During interview, the DON stated she was unaware that the existing curtains failed to provide full visual privacy and acknowledged there was a possibility of residents being exposed during resident care if the door was not closed. In a separate interview, the Administrator similarly acknowledged that if there was no full visual privacy in the resident rooms, there was a possibility of residents being exposed during resident care, and further stated that the facility did not have a policy on full visual privacy curtains.
Improper Placement of Industrial Dumpster on Dirt Surface
Penalty
Summary
The facility failed to provide a safe and sanitary environment by not properly situating its industrial-sized garbage dumpster. On observation, the dumpster was located at the back of the facility on a dirt surface rather than on a concrete slab. The dumpster placement was noted during a surveyor observation, and it was also identified that the facility did not have a policy governing dumpster placement or management. This deficiency pertains to the facility’s responsibility to maintain a safe, easy-to-use, clean, and comfortable environment for residents, staff, and the public. No specific residents, their medical histories, or conditions at the time of the deficiency were mentioned in the report.
Failure to Replace Damaged and Missing Ceiling Tiles in Hall 3
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in Hall 3 by not replacing missing and damaged ceiling tiles. Observations revealed that numerous ceiling tiles were either missing or damaged, leaving electrical wires and air ducting exposed. This condition was directly observed during a facility walkthrough and was confirmed through interviews with both a resident and facility staff. A resident reported that the ceiling tiles in Hall 3 had been in disrepair for an extended period, expressing dissatisfaction with the appearance and upkeep of the area. The Maintenance Director acknowledged that the tiles had been removed during recent air conditioning work, which had been completed weeks prior, but the tiles had not yet been replaced. The Administrator also confirmed that the ceiling tiles in Hall 3 were in need of replacement.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a prominent and accessible location for residents and visitors over a 12-day period. Observations on 08/20/25 revealed that the staffing information posted outside the Administrator's door was outdated, displaying the date 08/08/25. Interviews with the Administrator and the ADON confirmed that the daily staffing information had not been updated or posted for 12 consecutive days. The ADON, who was responsible for posting the information, stated that she had been busy with other job duties and had forgotten to keep the posting current. A review of the facility's policy, dated 01/01/2024, indicated that nurse staffing information should be made readily available in a readable format to residents and visitors at all times, with the staffing sheet posted daily. The Administrator acknowledged that she was unaware the postings were not current and reiterated that it was the ADON's responsibility to maintain the daily postings. No information was provided regarding any specific residents affected or their medical conditions at the time of the deficiency.
Failure to Update Care Plan After Fall Assessment
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident after a fall risk assessment was completed. The resident, an elderly female with multiple diagnoses including muscle wasting, dementia with agitation, anxiety disorder, gait abnormalities, and cachexia, was identified as high risk for falls. Despite a fall risk assessment indicating a high-risk score and an unwitnessed fall occurring in the resident's room while attempting to toilet herself, the care plan was not updated to reflect new interventions following the incident. The last documented update to the care plan was prior to the fall, and no new interventions were added after the assessment on the date of the fall. Interviews with nursing staff revealed that updates and interventions were communicated verbally and through 24-hour reports, rather than by reviewing or updating the care plan. Both the RN and CNA involved in the resident's care confirmed that they did not review care plans for updates, relying instead on verbal communication. The interim DON was unaware that the care plan had not been updated after the fall, and facility policy required that individual plans of care be implemented after each fall risk assessment.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of the Director of Nursing (DON) and a registered nurse (RN A) who did not adhere to Enhanced Barrier Precautions (EBP) during wound care for a resident. The resident, a cognitively intact male with a history of acute osteomyelitis, type II diabetes, and other health conditions, was admitted to the facility with a care plan that included EBP. Despite this, during an observation, both the DON and RN A neglected to wear gowns while providing wound care, which is a requirement under the facility's EBP policy. Interviews with the DON and RN A revealed that they were aware of the EBP requirements but failed to comply due to being busy and not thinking about it at the time. The facility's policy on EBP clearly states that gowns and gloves should be worn during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms. This oversight in following established procedures could potentially lead to cross-contamination and infection among residents.
Failure to Maintain Resident Dignity and Staff Cell Phone Use
Penalty
Summary
The facility failed to treat residents with respect and dignity, particularly during meal times and in the use of personal communication devices by staff. During an observation of the female locked unit's lunch meal, it was noted that meals were served on trays, which was different from the main dining room where meals were placed directly on the table. This practice was identified as institutional-like and not conducive to promoting a dignified existence for the residents. The Director of Nursing (DON) acknowledged the difference and questioned if it was a dignity issue, while a Certified Nursing Assistant (CNA) remarked that eating off a tray was reminiscent of high school, indicating a lack of consideration for the residents' dignity. Additionally, the facility failed to ensure that staff refrained from using personal cell phones while providing care, which was reported by residents during a confidential group interview. Residents expressed that staff were frequently on their phones during various care activities, including medication administration and dining room duties, making them feel ignored and isolated. Observations confirmed staff using phones while setting up smoking materials and the Activity Director using a phone in the dining room. The facility's Personnel Handbook prohibits the use of personal communication devices during work hours, except for designated personnel, yet this policy was not adhered to, contributing to the residents' diminished quality of life.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the improper wound care provided to Resident #15. The resident, a male with a chronic ulcer on his left foot, was admitted with a diagnosis of a non-pressure chronic ulcer. During a wound care procedure, RN B did not adhere to proper hand hygiene protocols, which is crucial in preventing cross-contamination and infection. Specifically, RN B failed to change gloves and perform hand hygiene at several critical points during the wound care process. RN B initially donned gloves and personal protective equipment (PPE) but did not clean the bedside table or use a barrier before placing wound care supplies. After removing gloves, RN B did not perform hand hygiene before donning new gloves to handle the resident's wound. The nurse repeatedly wiped the wound with the same gauze and failed to perform hand hygiene between glove changes. Additionally, RN B did not clean the wound care spray bottle after use, which could contribute to contamination. The Director of Nursing (DON) and the Administrator both acknowledged the importance of proper hand hygiene and aseptic technique during wound care. The DON noted that wiping the wound multiple times with the same gauze could re-contaminate the wound. Despite RN B's attendance at infection control in-services, the facility's policy and procedure for wound care were not followed, leading to a deficiency in the infection control program.
Facility Fails to Prepare Resident Rooms for Occupancy
Penalty
Summary
The facility failed to ensure that 33 out of 85 resident rooms were equipped for adequate nursing care, comfort, and privacy. These rooms, located in B Building, were not resident ready and had not been used for residents since 2020. The facility had identified certain rooms as Title 18 Medicare-Only beds and others as dually certified (Title 18/19) beds, but these rooms were not prepared for resident occupancy. The deficiency was identified through observation, interviews, and record review, revealing that the rooms were being used for storage and required deep cleaning and cosmetic repairs. Interviews with the Corporate Compliance RN and the Administrator confirmed that the rooms could not be made livable within a reasonable timeframe. The Administrator stated that the building had been used for storage since before her tenure began in 2023, and the corporate plan to remodel the building for a rehabilitation unit had not been prioritized due to low census. Despite the rooms being functional, they were not suitable for residents without thorough cleaning and repairs. The facility lacked a policy regarding bed classification, and the corporation was reluctant to declassify the rooms due to the cost of recertification.
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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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