Coleman Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Coleman, Texas.
- Location
- 2713 S Commercial Ave, Coleman, Texas 76834
- CMS Provider Number
- 675009
- Inspections on file
- 25
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Coleman Healthcare Center during CMS and state inspections, most recent first.
Kitchen staff failed to follow food safety practices when a DA entered the kitchen without a hair net and a cook touched bread with a bare hand while serving food. The CCS, DM, and dietician all stated staff in the kitchen should have worn hair restraints and gloves when handling ready-to-eat food, and the facility policy prohibited bare hand contact with food.
Unlicensed Administrator Oversaw Facility Operations: The facility failed to ensure that a state-licensed Administrator was responsible for management. The Assistant Administrator stated she had failed the licensure exam and was waiting to retest, while the RDO stated the facility had been without a licensed Administrator for several months. The RDO said the Assistant Administrator had been hired to become the licensed Administrator, and the DON stated he was the designated Abuse Coordinator if there was not an Administrator. The facility could not provide a policy regarding facility administration.
The facility failed to ensure 2 nurse aides were certified within the required timeframe. Record review showed one aide had worked full time since hire without CNA certification, and another had worked full time with no evidence of certification. The DON and ADON stated they knew both aides had not been tested; one aide had taken the CNA class twice without passing and needed special testing accommodation, while the other had completed NA training and was waiting for a test date.
Menu items and condiments not provided with lunch meal. A resident with a history of psychotic disturbance, mood disturbance, anxiety, and lack of coordination was on a regular, mechanical soft diet and had a care plan for nutritional risk. During a lunch meal observation, he was served soup and a baked potato but did not receive the dinner roll or requested condiments, and he stated he would not eat the potato without the sour cream and cheese he had asked for. Staff stated the condiments should have been on the tray and that the kitchen did not have the items for the alternate meal.
A resident’s pureed lunch was reheated in a microwave, and the pureed bread was observed dry, too thick, and too hot to serve. A CNA chose not to assist with feeding the bread because of the texture and temperature. The cook stated the meal was kept covered in the microwave until serving, while the CCS and Dietician stated hot foods should be held on the steam table and temperatures monitored; no temp log was found for the pureed food.
A resident with an indwelling urinary catheter was observed without a privacy cover on the catheter bag, despite physician orders and care plan requirements for such a cover to maintain dignity. The bag was visible from the hallway, and the resident reported never having seen a privacy cover. Facility staff, including an LVN, DON, and Administrator, acknowledged that the catheter bag should have been covered as ordered.
Surveyors found that two resident rooms were not thoroughly cleaned or sanitized, with sticky floors, trash, and food particles present under beds and behind furniture. Residents reported that housekeeping cleans several times a week but could not recall when the rooms were last swept or mopped, and none had reported the issue to staff. Facility staff confirmed that rooms should be cleaned daily or as needed, but were unaware of the unclean conditions in these rooms.
The facility reported an 8% medication error rate, exceeding the acceptable 5% threshold. Two residents received incorrect dosages due to LVNs not verifying medication orders properly. One resident with anxiety received an insufficient dose of buspirone, while another with bowel issues received an incorrect dose of dicyclomine. The DON attributed these errors to inattention, despite clear medication orders.
The facility failed to properly label and store insulin pens, leading to expired medications being available for administration. Insulin pens for three residents were found to be past their 28-day expiration period, with some lacking proper pharmacy labels. Staff interviews revealed a lack of adherence to medication storage and administration policies, potentially risking the administration of expired medications.
Kitchen Staff Failed to Use Hair Restraints and Gloves
Penalty
Summary
Food was not properly stored, prepared, distributed, and served in accordance with professional standards in the kitchen. During an observation on 03/03/2026 at 9:59 AM, the DA was wearing a baseball cap with hair pulled through the back in a ponytail and did not have a hair net on while in the kitchen. During the same observation, the [NAME] was seen touching bread with a bare hand while serving food. During interviews, the CCS stated all staff in the kitchen should have been wearing a hair net and that even if a ball cap was worn, no hair should have been uncontained. The CCS also stated staff touching food had to be gloved and that the DM should have monitored kitchen staff better. The DM stated all staff entering or working in the kitchen should have a hairnet on before entering the food preparation and serving area, and that food should not have been touched without gloves. The dietician stated staff entering the kitchen should have a hairnet, that a ball cap alone was not appropriate if hair was out, and that ready-to-eat food should not have been touched without gloves. Record review of the facility policy stated bare hand contact with food is prohibited, gloves are worn when handling food directly, and food service staff wear hair restraints so hair does not contact food.
Unlicensed Administrator Oversaw Facility Operations
Penalty
Summary
The facility failed to ensure that it had an Administrator licensed by the state who was responsible for facility management. During interview on 3/06/2026 at 3:30 p.m., the Assistant Administrator stated that she had failed the test to become a licensed Administrator and was waiting for a retest date. She stated that the Regional Director of Operations was the licensed Administrator covering the building and that she could call her if needed. She also stated there was no negative outcome for residents due to her lack of a valid Administrator license. During interview on 03/06/2026 at 3:45 p.m., the RDO stated the facility had been without a licensed Administrator for several months. She stated the Assistant Administrator had been hired to move into the licensed Administrator position after passing the licensure exam, but she failed the examination and had applied to test again. She stated she had not been actively seeking a licensed Administrator because the job had been promised to the Assistant Administrator. During interview on 03/07/2026 at 4:15 p.m., the DON stated he was the designated Abuse Coordinator if there was not an Administrator. Record review of the facility's Active Employee Report showed the Assistant Administrator was hired on 07/23/2024, and during the exit conference on 03/06/2026 at 5:00 p.m., the facility was unable to provide a policy regarding facility administration.
Uncertified nurse aides worked beyond required timeframe
Penalty
Summary
The facility failed to ensure that nurse aides were certified within the required time frame for 2 of 5 nurse aides reviewed, NA C and NA D. Record review showed NA C had a hire date of 4/08/2024, worked full time, and had no evidence of nurse aide certification. NA D had a hire date of 03/21/2025, worked full time, and also had no evidence of nurse aide certification. The report states that both aides had worked in the facility longer than four months without being enrolled in or having completed an approved training course. During interview, the DON and ADON stated the expectation was for the facility to have certified nurse assistants. The ADON stated that both she and the DON were aware that NA C and NA D had not been tested. She stated there had been no certified applicants and the facility had only been able to hire NAs. She also stated that NA C had previously been terminated for not having CNA certification, had taken the CNA class twice without passing the test, and required special accommodation for testing. NA D had completed NA training on 06/25/2025 and was waiting on a test date. The facility policy titled The Role of the Hospitality Aide described duties for hospitality aides, including non-nursing, non-direct care duties under supervision of licensed nursing personnel.
Menu items and condiments not provided with lunch meal
Penalty
Summary
The facility failed to ensure the menu was followed for 1 observed lunch meal. Resident #11, an [AGE]-year-old male with diagnoses including psychotic disturbance, mood disturbance, anxiety, and lack of coordination, had a care plan addressing nutritional risk related to protein-calorie malnutrition. His physician orders included a regular diet with mechanical soft texture and thin liquids. The facility menu for the lunch meal listed shrimp fettuccini alfredo, green beans, a dinner roll, gelatin with whipped topping, tableside condiments, a beverage, and water, with an alternative of baked potato with condiments, soup, and hamburger. During the noon meal observation, Resident #11 was served soup, a baked potato, and no roll. He stated he had requested the roll and extra sour cream with his baked potato, and that because he had not received the requested sour cream and cheese, he was not going to eat it. The dietary manager stated the condiments should have been on the tray and that the kitchen had no sour cream or cheese for the baked potato alternative during lunch service. She also stated it was her responsibility to order enough food and condiments. The CCS stated all residents should have received all products listed on the menu, including condiments, and the dietician stated all residents should always receive all food listed on the menu unless there was an allergy.
Pureed Meal Reheated Improperly and Served Too Hot
Penalty
Summary
The facility failed to provide a lunch meal that was flavorful and palatable because the pureed meal and pureed bread were prepared and reheated in a microwave. During an observation at 12:00 PM, the cook placed the pureed meal and pureed bread in the microwave for reheating. Later, at 12:35 PM, a CNA was assisting residents with a pureed meal and observed that the pureed bread looked dry and too thick, and the CNA did not assist the resident with eating the pureed bread. During interviews, the cook stated she prepared the one resident’s pureed meal and kept it covered in the microwave until serving time, then reheated it in the microwave. The CNA stated she decided not to assist feed the resident the pureed bread because it was too thick and too hot to serve, and she stated there was a possibility of the resident getting burned or choking. The CCS stated food should have been placed on the steam holding table prior to serving and was not sure why the cook used the microwave instead. The DM stated all food should be temped correctly prior to transport to the resident, and the Dietician stated all food temperatures should be held on the steam table, not the microwave. Record review showed no temperature log for the pureed food, and the facility policy required mechanically altered hot foods to remain above 135 degrees Fahrenheit during preparation or be reheated to 165 degrees Fahrenheit for at least 15 seconds.
Failure to Provide Privacy Cover for Catheter Bag Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a male resident with a history of kidney disease, heart failure, ureteral obstruction, and cerebral infarction was observed with an indwelling urinary catheter bag that was not covered by a privacy bag. The resident's care plan and physician's orders specifically required the use of a privacy bag to cover the catheter bag for dignity. During the observation, the catheter bag was visible from the hallway due to the resident's open door, and the resident reported never having seen a privacy bag cover for his catheter. He expressed that having the bag covered would be preferable and more dignified. Interviews with facility staff, including an LVN, the DON, and the Administrator, confirmed awareness that catheter bags should be covered with a privacy bag as per care plan and physician orders. The LVN was unsure why the privacy bag was not in place and acknowledged the importance of covering the catheter bag for dignity. Both the DON and Administrator stated that failing to cover the catheter bag could result in dignity issues for residents, especially when it is part of the care plan and physician's orders.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
Surveyors observed that resident rooms #302 and #306 were not thoroughly cleaned or sanitized, with sticky and stained floors, trash, candy wrappers, and food particles found under beds, behind dressers, and nightstands. Both rooms also had a foul odor. Residents occupying these rooms reported that housekeeping generally cleans several times a week, but could not recall when the rooms were last swept or mopped. Residents expressed a preference for a clean environment and noted that the floors were sticky, with one resident mentioning a recent tea spill that had not been cleaned. None of the residents had reported the unclean conditions to staff. Interviews with facility staff, including a CNA, LVN, and the Housekeeping Director, confirmed that rooms are expected to be cleaned daily or as needed, including sweeping and mopping under beds and behind furniture. Staff stated that they notify housekeeping if a room needs attention, but were unaware of the unclean conditions in these specific rooms. The Housekeeping Director acknowledged the expectation for thorough cleaning and recognized the importance of maintaining a clean and sanitary environment for residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. This was based on two errors out of 25 opportunities involving two residents. One resident, a male with a history of brain bleed, cognitive decline, and diabetes, was administered only one tablet of buspirone 5mg instead of the prescribed two tablets. The error occurred because the LVN did not pay attention and failed to verify the correct dosage, which could lead to inadequate anxiety relief for the resident. Another resident, a female with diagnoses including abdominal hernia with obstruction, lung disease, and heart failure, was given one tablet of dicyclomine 20mg instead of the prescribed two tablets. The LVN responsible admitted to being nervous and not checking the dosage, and was unaware of the medication's purpose. The Director of Nursing acknowledged that the errors were due to inattention, despite clear orders, and emphasized that the residents did not receive the intended therapeutic doses.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed in the Hall 300/400 medication cart. Specifically, insulin pens for three residents were found to be improperly labeled and expired. A Humulin R flex pen for one resident was opened on 10/20/2024, an Insulin Glargine flex pen for another resident was opened on 10/18/2024, and a Lantus flex pen for a third resident was opened on 10/12/2024, all of which were past the 28-day expiration period. Additionally, the Lantus and Insulin Lispro pens for the third resident lacked proper pharmacy labels and were marked with the resident's name in marker, with the Insulin Lispro pen missing an open date entirely. Interviews with staff revealed a lack of adherence to the facility's medication storage and administration policies. LVN A acknowledged that insulin vials and pens should be dated when opened and discarded after 28 days, and that all medications should have the original pharmacy label. The Director of Nursing (DON) confirmed that it was the nurse's responsibility to ensure medications were not expired before administration. The facility's policies require that drug containers with missing or incorrect labels be returned to the pharmacy for proper labeling and that expired medications be removed. The failure to comply with these policies could lead to residents receiving expired medications.
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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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