Cherokee Rose Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Glen Rose, Texas.
- Location
- 203 Gibbs Blvd, Glen Rose, Texas 76043
- CMS Provider Number
- 675008
- Inspections on file
- 29
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Cherokee Rose Nursing And Rehabilitation during CMS and state inspections, most recent first.
Resident council meetings were not held in a private space because staff repeatedly walked through the dining room during the meetings. Residents said the interruptions prevented privacy and could allow their concerns to be overheard, while the AD and ADMN acknowledged staff sometimes crossed through the area despite posted signs and closed doors. The facility policy stated resident council would be provided private space and that staff could attend only by invitation.
A resident with COPD and HTN had orders for lisinopril and diltiazem with specific BP hold parameters, but MAR review showed both medications were given multiple times when recorded BP values were below the ordered limits. An MA stated she did not realize the resident had those specific parameters, and the DON stated staff were expected to follow physician orders and MAR parameters.
A dietary staff member pureed BBQ chicken, macaroni and cheese, and beans for a resident meal and left them at temperatures of 107 F, 106 F, and 119 F without reheating them before service. The DM also mechanically altered BBQ chicken for a mechanical soft diet without checking the temperature after alteration. Staff interviews confirmed the foods were served without being reheated to the required temperature.
Improper Storage of Nebulizers for Two Residents: Two residents receiving ordered nebulizer treatments had their nebulizers found not bagged and not dated when not in use. One resident had COPD and the other had acute respiratory failure; both were cognitively intact and on oxygen therapy. The DON stated nebulizers and oxygen tubing not in use should be placed in a plastic bag, and the facility policy required the nebulizer to be rinsed and stored in a labeled plastic bag.
Menu Not Followed for A Resident on Pureed Diet A resident with dysphagia, severe cognitive impairment, hospice services, and weight loss was on a pureed diet with health shakes. The posted lunch menu included a Honey Kissed Roll, and the tray ticket listed a pureed roll to be offered, but staff did not provide one. The cook stated she forgot to puree the roll, while other staff said the resident would choke on a roll and did not consider pureeing it, despite the expectation that all menu items be offered.
A resident with multiple medical conditions was provided with bed rails for mobility without a documented assessment for entrapment risk or informed consent from the resident or representative. Staff interviews confirmed that required assessments and consents were not completed prior to installation, contrary to facility policy.
The facility failed to ensure call lights were within reach for three residents, all with cognitive impairments and mobility issues. Observations revealed that call lights were either on the other side of the room or between the headboard and mattress, making them inaccessible. Staff interviews confirmed the expectation for call lights to be within reach, but unplanned construction and lack of a specific policy contributed to the oversight.
The facility failed to properly store and label medications on the C Hall medication cart and in the medication room. Loose pills were found in unlabeled cups, and the cart keys were left unattended in a binder on top of the cart. The DON and ADON were responsible for monitoring proper storage, but protocols were not followed, posing potential risks of medication errors and unauthorized access.
The facility did not follow the posted menu for a lunch meal, substituting items due to unavailable ingredients, which could affect residents' nutritional intake. The Dietary Manager noted missing substitution logs and a lack of inventory oversight, leading to deviations from the planned menu.
The facility failed to maintain food safety standards, including improper hand hygiene during meal prep, lack of labeling for open food items, and inadequate sanitization of thermometers. These actions could lead to foodborne illnesses and cross-contamination, as acknowledged by the Regional Certified Dietary Manager.
The facility failed to maintain effective infection control practices, as observed in two incidents. A CNA did not wear appropriate PPE while caring for a COVID-19 positive resident, and the resident was transported without a mask. Additionally, an LVN did not perform proper hand hygiene between obtaining a blood sample and administering insulin. These actions were contrary to the facility's infection control policies, highlighting deficiencies in PPE use and hand hygiene practices.
A facility failed to complete a Significant Change Assessment for a resident admitted to hospice care, despite the resident's severe cognitive impairment and serious health conditions. The MDS nurse responsible for the assessment was on sick leave, and miscommunication led to the oversight. The facility relied on the CMS's RAI Manual for guidance, lacking a specific policy for such assessments.
A facility failed to update a comprehensive care plan for a resident on hospice, despite a physician order. The resident, with severe cognitive impairment and multiple serious diagnoses, was admitted to hospice, but this was not reflected in the care plan. The MDS nurse responsible for updates was on sick leave, leading to miscommunication and the absence of a Significant Change Assessment. The DON acknowledged the oversight, which could have resulted in incorrect services for the resident.
A facility failed to document a hospice admission order in a resident's medical records, despite the resident having severe cognitive impairment and multiple serious health conditions. The order was only found in hospice records, not in the facility's electronic records or the resident's care plan. The DON stated the omission was due to a nurse forgetting to transcribe the order, contrary to facility policy.
Resident Council Meetings Lacked Privacy
Penalty
Summary
The facility failed to provide a private meeting space for resident council meetings, and staff continued to interrupt the meetings by walking through the dining room. During an observed confidential group meeting on 03/25/2026 between 1:30 p.m. and 1:50 p.m., a facility staff member opened the dining room door, walked through the dining room to the kitchen with a cup, then returned through the dining room and exited. Resident council members stated staff came in and out of the dining room during meetings and that the AD had placed signs at both entrances asking staff not to enter while resident council was being held, but staff did not respect the signs. The residents stated they felt their concerns may be overheard when staff cut through the dining room during the meetings. During interviews, the AD stated she closed the dining room doors and posted signs during resident council meetings to try to keep people from coming in, and she acknowledged that staff sometimes walked through the dining room to get items from the kitchen during the meetings. She stated she had asked staff to leave before when they were sitting at a table during resident council and did not feel the meetings were private. The ADMN stated staff were expected not to walk through the dining room during resident council meetings, that the door should remain shut, and that signs were posted to notify staff not to enter. He also stated staff had to walk through the dining room to get drinks for residents who did not attend the meetings if they wanted something other than water stored on the halls. The facility policy titled Resident Council stated the facility would provide the resident council with private space and that staff, visitors, or other guests may attend only at the group's invitation.
Failure to Follow Blood Pressure Medication Hold Parameters
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met for one resident. Resident #13, a [AGE]-year-old female with COPD and hypertension, had physician orders for lisinopril 40 mg daily to be held if blood pressure was less than 140 systolic or 90 diastolic, and diltiazem 60 mg three times daily to be held if systolic was less than 140 or diastolic less than 90. Her quarterly MDS dated 03/03/2026 showed a BIMS score of 15, and her care plan identified hypertension with anti-hypertensive medications ordered. Review of the MAR showed lisinopril was administered six times in March 2026 when the recorded blood pressures were below the ordered hold parameters. The MAR also showed diltiazem was administered 22 times in March 2026 when the recorded blood pressures were below the ordered hold parameters. During interview, MA-D stated she did not realize the resident had those specific parameters and would have only noticed a systolic below 110 because that was the standard parameter. The DON stated staff were expected to follow physician orders and read the MAR for parameters, and the NP stated nurses were expected to follow the ordered parameters.
Food Not Reheated After Pureeing or Mechanical Alteration
Penalty
Summary
The facility failed to properly prepare and serve food in accordance with professional standards during lunch meal service for one kitchen reviewed. During observation, a staff member pureed BBQ chicken, baked macaroni and cheese, and homestyle beans for a resident’s meal, placing each item on a divided plate without taking temperatures at the time of preparation. The pureed foods were left by the blender and then moved to the steam table area, but no temperature checks were documented before service. When the temperatures were later taken, the pureed BBQ chicken measured 107 degrees F, the pureed baked macaroni and cheese measured 106 degrees F, and the pureed homestyle beans measured 119 degrees F. The staff member did not reheat any of the pureed food items after these temperatures were found. The food was then handed off for dining room delivery and served to the resident without being reheated prior to service. The observation also showed the dietary manager mechanically altered BBQ chicken to a mechanical soft texture and placed it into a pan on the steam table without taking the temperature after the texture change. The meal was later served to residents on a mechanical soft diet. Interviews with dietary and administrative staff confirmed that the food should have been reheated to the appropriate temperature after being found below holding temperature and after mechanical alteration, and that the temperature checks were not completed as expected.
Improper Storage of Nebulizers for Two Residents
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents who were receiving nebulizer treatments. Resident #13 had COPD, no cognitive impairment with a BIMS score of 15, and was on oxygen therapy. Her care plan directed staff to give aerosol or bronchodilator treatments as ordered, and physician orders included albuterol sulfate inhalation nebulization solution as needed for cough, congestion, or shortness of breath and budesonide inhalation suspension twice daily for COPD. During observation, Resident #13's nebulizer was found laying on the bedside table, not bagged, and with no date. The resident stated she had laid it there when her treatment was finished. Resident #20 had acute respiratory failure, no cognitive impairment with a BIMS score of 15, and was on oxygen therapy. Her care plan directed staff to give medications as ordered, and the physician order included ipratropium-albuterol inhalation solution every 4 hours as needed for shortness of breath. During observation, Resident #20's nebulizer was found lying in a drawer, not bagged, and not dated. She stated that the nurse had placed it there when her treatment was done. The DON stated that nebulizers and oxygen tubing not in use should have been placed in a plastic bag and that the nebulizer should have been placed in the bag after treatment; the facility policy also stated the nebulizer should be rinsed and stored in a labeled plastic bag.
Menu Not Followed for Pureed Diet Resident
Penalty
Summary
The facility failed to follow the posted menu for a resident on a pureed diet. Resident #19 was a female with dysphagia and cognitive communication deficit, had a BIMS score of 01 indicating severe cognitive impairment, and had a history of weight loss with hospice services and poor oral intake. Her care plan and dietitian notes reflected significant unplanned weight loss, a pureed diet, and health shakes three times daily. The record also stated there was no evidence she should not have pureed bread. On 03/24/2026, the posted lunch menu in the dining room listed BBQ Chicken Quarter, Baked Macaroni & Cheese, Homestyle beans, Honey Kissed Roll, and Apple Cobbler. During observation, the dietary staff member preparing the meal stated there was only one resident on a pureed diet and that no roll was pureed for Resident #19. At lunch, the resident was observed being fed pureed food, but there was no pureed roll on her tray. The ticket next to the tray listed a pureed honey kissed roll among the items to be offered, but the roll was not present. Interviews showed staff believed the resident could not have a roll because she was on a puree diet and would choke, while the dietary manager stated the expectation was that residents on a pureed diet be offered all menu items and believed the cook had pureed the roll. The cook stated she did not puree a roll and said she forgot to do so. The administrator stated the resident should have received all menu items unless bread was contraindicated, and the dietary manager and kitchen staff were responsible for ensuring the menu was followed.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for risk of entrapment from bed rails prior to their installation and did not review the risks and benefits of bed rails with the resident or the resident's representative, nor did it obtain informed consent before installation. Specifically, a cognitively intact female resident with a history of right femur fracture, hypertension, heart disease, and weakness was admitted and had physician orders for quarter bed rails to assist with mobility. The care plan included the use of side rails for safety and mobility, with instructions to observe for injury or entrapment and reposition as needed. However, there was no evidence in the resident's electronic medical chart of a completed bed rail assessment or signed consent for bed rail use. Observations confirmed the presence of bed rails on both sides of the resident's bed, and interviews with the resident and her representative revealed that the representative did not recall signing a consent form. Facility staff, including the ADON and ADMN, acknowledged that assessments and consents should have been completed and documented prior to bed rail installation, as required by facility policy. The failure to complete these steps was attributed to turnover in the DON position.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of three residents by not ensuring their call lights were within reach. Resident #8, a female with severe cognitive impairment and a history of falls, was observed lying in bed with her call light on the other side of the room's privacy curtain, out of her reach. Her care plan specifically required that her call light be within reach to mitigate her fall risk. Resident #21, who has moderate cognitive impairment and is dependent on staff for transfers, was found with her call light hanging between the headboard and mattress, not within arm's length. During an interview, she expressed a desire for more coke but was unable to call for assistance due to the inaccessible call light. Her care plan also emphasized the importance of having the call light within reach to prevent falls. Resident #37, with severe cognitive impairment and dependent on staff for transfers, was observed with her call light on the other side of the room's privacy curtain, similar to Resident #8. Interviews with staff, including CNAs and the DON, confirmed that the expectation was for all residents to have call lights within reach. The DON and ADMN acknowledged that the relocation of residents due to unplanned construction might have contributed to the oversight, but no specific policy was in place to ensure call lights were consistently accessible.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional principles, specifically on the C Hall medication cart and in the medication room. During an observation, it was found that the C Hall medication cart contained 15 loose pills in unlabeled medication cups, which were stored improperly after residents refused them. The medication aide, MA D, admitted to storing these medications incorrectly and acknowledged her responsibility for proper storage. Additionally, the keys to the medication cart were left unattended in a binder labeled 'Narcotic Book C Hall' on top of the cart, which was against the facility's policy. Further observations revealed that the C Hall medication cart was left unattended outside the nurses' station, with the keys still in the binder. LVN E, who was present, stated that the keys should be kept on the person responsible for the cart and not left unattended. The cart contained various medications, including heart medications, psychotropic drugs, nasal spray, and narcotics. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were responsible for monitoring the proper storage of medications, but the failure to adhere to these protocols was evident. Interviews with the DON, ADON, and the consultant pharmacist (CP) highlighted the expectation that medications should be discarded if refused by residents and that keys should remain with the responsible staff member. The facility's policies on medication storage and labeling were not followed, leading to potential risks of medication errors and unauthorized access. The report did not indicate any specific negative outcomes for residents but emphasized the importance of adhering to proper storage and labeling practices to prevent such risks.
Failure to Follow Menu and Ensure Nutritional Needs
Penalty
Summary
The facility failed to ensure that the menus met the nutritional needs of residents and were followed as per the established guidelines. On the observed date, the lunch meal did not include the items listed on the posted menu, which were recommended by the licensed dietician. Instead of the planned grilled steak with onions, baked potatoes, and sauteed broccoli, the facility served Salisbury steak, garlic parmesan mashed potatoes, and mixed vegetables. Additionally, cheesecake with fruit topping was substituted with green Jell-O with fruit. The staff member responsible for preparing the meal admitted to not following recipes and substituting items due to the unavailability of the listed ingredients. The Regional Certified Dietary Manager expressed concerns that the substitutions could alter the overall calorie intake and negatively impact the residents' diets. It was revealed that prior to the new Dietary Manager's appointment, inventory was not completed, leading to a lack of necessary ingredients. The Dietary Manager confirmed that the substitution logs were blank, and previous logs were missing, indicating a lack of oversight and supervision in ensuring that the dietary staff followed the menu. The facility's policy required that any meal variation from the planned menu be recorded on the substitution log, which was not adhered to in this instance.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Staff did not practice appropriate hand hygiene during meal preparation, which included failing to wash hands after handling various items and before engaging in food preparation tasks. This was observed when staff members handled food items, such as Jell-O containers and hamburger patties, without washing their hands before or after glove use, and after touching potentially contaminated surfaces like trash cans. Additionally, the facility did not label open food items with the date they were opened or their expiration dates. This was noted with several food items, including bags of cabbage, pudding containers, and pita bread, which were stored in the refrigerator without proper labeling. The Dietary Manager admitted to not knowing how long some items had been stored, which could lead to the use of spoiled food. The facility also failed to ensure that thermometers used for checking food temperatures were properly sanitized between uses. A staff member was observed using a thermometer on different food items without cleaning it in between, which could lead to cross-contamination. The Regional Certified Dietary Manager acknowledged that these practices did not meet the facility's expectations and could negatively impact residents by spreading germs and causing foodborne illnesses.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved a Certified Nursing Assistant (CNA) who did not wear appropriate personal protective equipment (PPE) while providing care to a resident with an active COVID-19 infection. The CNA was observed exiting the resident's room wearing only a surgical mask and gown, without gloves or a face shield, and transported the resident to the shower room without the resident wearing a mask. The CNA admitted to not being informed about the resident's COVID-19 status and acknowledged that the resident should have been masked during transportation. Another deficiency was noted with a Licensed Vocational Nurse (LVN) who failed to perform proper hand hygiene while obtaining a blood sample for glucose testing. The LVN did not change gloves or sanitize hands between handling the glucometer and administering insulin to the same resident. This practice was contrary to the facility's infection control policies, which emphasize the importance of hand hygiene to prevent cross-contamination and infection spread. The Director of Nursing (DON) confirmed that the LVN's actions were not in line with expected procedures and acknowledged that staff had been trained on infection control. The facility's policies on infection control and COVID-19 precautions were not adequately followed, as evidenced by the lack of appropriate PPE use and hand hygiene practices. The DON and medical director provided insights into the expected standards of care, including the use of masks, gowns, gloves, and face shields when caring for COVID-19 positive residents. However, the observed practices did not align with these expectations, indicating a gap in the implementation of the facility's infection control program.
Failure to Complete Significant Change Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Assessment for a resident who was admitted to hospice care. The resident, a male with severe cognitive impairment and multiple serious health conditions, including a traumatic brain injury, sepsis, respiratory failure, and Type 2 diabetes, was admitted to the facility and later to hospice. Despite the hospice admission, there was no evidence of a Significant Change Assessment being completed, which is required to accurately reflect the resident's current medical condition and ensure appropriate care. Interviews with facility staff revealed that the Director of Nursing (DON) expected the assessment to be completed within 14 days of the hospice admission. The MDS nurse, who was responsible for completing the assessment, was on sick leave, and the responsibility fell to the RRN. The RRN acknowledged that the hospice admission should have triggered the assessment, but miscommunication led to the failure. The nurse who received the hospice order did not enter it into the system, which would have prompted the assessment process. The facility did not have a specific policy for Significant Change Assessments, relying instead on the CMS's RAI Manual.
Failure to Update Care Plan for Hospice Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was on hospice, which was not reflected in the care plan. The resident, a male with severe cognitive impairment, was admitted with multiple serious diagnoses including traumatic subdural hemorrhage, sepsis, respiratory failure, and Type 2 diabetes. Despite a physician order to admit the resident to hospice, the care plan was not updated to reflect this significant change. The Director of Nursing (DON) acknowledged that the care plan should have been updated following a Significant Change Assessment, which was not completed. The failure to update the care plan was attributed to miscommunication and the absence of a Significant Change Assessment. The MDS nurse, who was responsible for updating the care plan, was on sick leave, and the responsibility fell to the RRN, who did not complete the necessary updates. The facility lacked a specific policy for Significant Change Assessments, relying instead on the CMS's RAI Manual. The oversight could have resulted in the resident receiving incorrect services, as the care plan did not reflect the resident's hospice status.
Failure to Document Hospice Admission in Resident's Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of hospice care. The resident, a male with severe cognitive impairment and multiple serious health conditions, was admitted to the facility with a diagnosis of traumatic subdural hemorrhage, sepsis, respiratory failure, and Type 2 diabetes. Despite a physician order to admit the resident to hospice on a specific date, this order was not entered into the facility's electronic medical records, nor was it reflected in the resident's comprehensive care plan. During an interview, the Director of Nursing (DON) acknowledged that the nurse responsible for receiving physician orders should have entered the order into the electronic medical records system. The DON admitted that the failure to update the comprehensive care plan with hospice information was due to the charge nurse forgetting to transcribe the record. The facility's policy requires nurses to review and enter physician orders into the electronic charting system, which was not followed in this instance.
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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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