Colonial Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lindale, Texas.
- Location
- 508 Pierce St, Lindale, Texas 75771
- CMS Provider Number
- 675563
- Inspections on file
- 28
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Colonial Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A medication cart was found to contain 15 expired tablets of APAP/Codeine 300-30mg that had not been removed from use, despite facility policy and staff training requiring regular checks and removal of expired medications. The expired medication was discovered during an observation and interview with an RN, and the DON confirmed that such medications should not be present in storage areas.
The facility failed to maintain RN coverage for 8 consecutive hours, 7 days a week, on multiple dates in December 2024 and January 2025. Interviews with staff confirmed the absence of a full-time RN, which is required by the facility's policy. This deficiency left residents without access to staff with advanced care skills, potentially affecting their care needs.
The facility failed to appoint a full-time Director of Nursing (DON) since early November 2024, as confirmed by interviews and record reviews. The absence of a DON was acknowledged by both the administrator and the Assistant Director of Nursing (ADON), who started their roles after the last recorded day of DON coverage. This lack of a designated DON could risk residents due to insufficient nursing oversight.
The facility's kitchen operations were found deficient in maintaining sanitary conditions, with improperly sealed food items and incorrect use of test strips for dish sanitization. The dish machine log was pre-filled with inaccurate data, and several thickened liquid products were not labeled with opening dates. These issues could place residents at risk of foodborne illness.
The facility failed to accurately assess three residents' PASRR status, leading to incorrect MDS coding. A resident with bipolar disorder and another with psychotic disorder were both inaccurately coded as not having a serious mental illness, despite positive PASRR screenings. The MDS Coordinator misunderstood the coding requirements, resulting in these inaccuracies.
A facility failed to ensure proper medication administration for a resident with a G-Tube. The resident's medications were crushed and administered together without the required water flushes, contrary to facility policy. This action led to a blockage in the G-Tube, and the LVN did not follow the correct procedure, potentially risking tube damage and complications.
The facility failed to properly administer medications to two residents, leading to potential risks. A resident with a gastrostomy tube received improperly crushed medications without required water flushes, while another resident with severe cognitive impairment did not receive the prescribed Vitamin B12 dose due to unavailability, leading to unauthorized dose calculations by a Medication Aide. These actions violated facility policies and physician orders, highlighting deficiencies in medication administration practices.
A facility reported a medication error rate of 7% due to improper administration of medications via a gastrostomy tube. An LVN crushed a delayed-release medication, Protonix, and administered it with other medications, contrary to physician orders and facility policy. The resident involved had a gastrostomy tube and intact cognition. The LVN admitted to the error, and the ADON confirmed non-compliance with medication administration policies.
A facility failed to accurately document a resident's code status, leading to a discrepancy between the resident's wishes and the facility's records. The resident, with severe cognitive impairment and multiple health issues, had a signed OOHDNR document, but staff believed she was Full Code due to lack of communication and documentation errors. This oversight could have led to resuscitation actions against the resident's wishes.
A facility failed to maintain an effective infection prevention and control program when an LVN did not adhere to Enhanced Barrier Precautions while administering medications through a gastrostomy tube to a resident. Despite the requirement to wear gloves and a gown for high-contact activities, the LVN only donned gloves, contrary to the facility's policy and CDC guidelines. Interviews confirmed the necessity of these precautions for residents with indwelling medical devices to prevent infection spread.
A facility failed to protect residents from abuse and neglect, with incidents involving both staff and resident aggression. A resident reported being assaulted by an MA, but the facility did not investigate or report the incident. Another resident was left unsupervised for hours, resulting in a fall. Additionally, a resident with a history of aggression was involved in multiple incidents of abuse towards other residents, which the facility failed to adequately address.
The facility failed to implement its abuse and neglect policies, resulting in multiple incidents involving residents. A resident reported being assaulted by a staff member, but the facility did not investigate or suspend the alleged perpetrator. Another resident was left unattended for hours, resulting in a fall. Additionally, the facility did not protect residents from abuse by other residents, with incidents of inappropriate touching and physical aggression not properly addressed.
A resident with severe cognitive impairment and paralysis fell during a mechanical lift transfer conducted by a CNA working alone, despite the care plan requiring two staff members. The incident occurred due to a strap coming off the Hoyer lift, which had smaller hook holders. The CNA admitted to not asking for assistance and was terminated for not following protocol.
A resident with multiple medical conditions, including double amputation and cognitive impairment, slid out of a manual wheelchair during transportation due to improper securement by the driver. The driver, who was not a CNA, did not call emergency services and continued to transport the resident on the floor of the van. Upon arrival at the facility, staff assessed the resident and called EMS for hospital evaluation. The incident highlighted a failure to follow the facility's transportation policy and inadequate care planning for the resident's needs.
A resident's Hydrocodone medication was delivered to the facility but was not accounted for, leading to a deficiency in pharmaceutical services. The medication, prescribed for pain management following surgical amputation, was signed for by an LVN but could not be located afterward. The facility's policies on medication storage and destruction were not followed, resulting in a lack of proper documentation and control over the medication.
Expired Medication Not Removed from Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with regulatory requirements, specifically by not removing expired medication from a medication cart. During an observation and interview, it was found that a medication cart on A Hall contained an individual medication card with 15 tablets of APAP/Codeine 300-30mg that had expired 10 days prior. The medication was stored in a locked compartment, but had not been removed from use. The responsible RN confirmed the medication was expired and stated she had not administered any of the expired tablets. She also indicated she was trained to check for expired medications and maintain the cart free of such items. The DON stated that expired medications should not be present in medication carts or rooms and that nurses are expected to check for and remove expired medications during each shift. Review of the facility’s control drug record showed the medication was last administered prior to its expiration, and pharmacy monthly reviews did not identify the expired medication for removal. Facility policy requires that outdated drugs be returned to the pharmacy or destroyed, but this process was not followed in this instance.
Failure to Maintain RN Coverage in Facility
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for 8 consecutive hours, 7 days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that there was no RN coverage on multiple dates in December 2024 and January 2025. Specifically, the facility lacked RN coverage from December 2 to December 9, December 13 to December 18, December 20 to December 22, December 25, and from December 28 to January 6, 2025. The absence of an RN during these periods meant that residents did not have access to staff with advanced care skills, which could potentially affect their care needs. Interviews with facility staff, including the Administrator and the Business Office Manager (BOM), confirmed the lack of a full-time RN. The Administrator acknowledged the potential negative outcomes of not having an RN on duty, such as staff being unprepared to handle emergencies. The BOM also noted the absence of an RN as a lack of an additional set of eyes for resident care but was unaware of the reasons behind the staffing shortfall. The facility's Departmental Supervision policy, dated April 2006, mandates that nursing services be supervised by an RN or LPN/LVN at all times, with an RN employed as the Director of Nursing Services (DNS) during the day shift, Monday through Friday. However, this policy was not adhered to during the specified dates.
Failure to Designate a Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis since November 3, 2024. This deficiency was identified through interviews and record reviews, which revealed that the last day of DON coverage was on November 3, 2024. The facility's administrator, who began employment on November 25, 2024, confirmed that there was no DON at the time of her hiring. Additionally, the Assistant Director of Nursing (ADON), who started on November 11, 2024, also confirmed the absence of a DON. Further investigation showed that the facility's policy requires the Nursing Services department to be managed by a full-time DON, who is a licensed RN with experience in nursing administration, rehabilitation, and geriatric nursing. Despite this requirement, the facility has been unable to employ a DON, as confirmed by the current administrator, who started his role on January 7, 2025. The absence of a DON could place residents at risk due to a lack of nursing oversight and a higher level of care.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, which could potentially place residents at risk of foodborne illness. During an inspection, it was observed that a 16 oz. bag of tortilla chips was opened and not properly resealed. Additionally, in the walk-in cooler, several thickened liquid products, including nectar thick iced teas, nectar thick orange juice, and honey thick water with lemon, were opened but not labeled with the date they were opened, contrary to the packaging instructions that specified a limited shelf life after opening. The dishwashing process was also found to be deficient. The dietary aide (DA A) was using quaternary ammonia test strips instead of the correct chlorine test strips to check the sanitizing solution in the dish machine. This error was due to the incorrect test strips being left by the dish machine vendor, and DA A was unaware of the mistake. Furthermore, the dish machine log was pre-filled with results for a meal that had not yet occurred, and there were missing entries for sanitizing conditions on several dates. The dietary manager (DM) was unaware of these issues and did not regularly check the sanitizing logbook. The facility's policies on dishwashing and food storage were not adhered to, as evidenced by the incorrect use of test strips and the lack of proper labeling and storage of food items. The DM did not ensure that the dishwashing machine was checked for proper sanitizer concentrations regularly, and the facility's Refrigerators and Freezers policy was not followed, as expired or improperly labeled food items were found in storage. These lapses in protocol could compromise the safety and quality of food served to residents.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents regarding their Preadmission Screening and Resident Review (PASRR) status. Resident #16, a male with bipolar disorder and depressive disorder, was inaccurately coded in the Minimum Data Set (MDS) as not having a serious mental illness, despite having a PASRR Level 1 screening indicating a primary diagnosis of dementia. Similarly, Resident #52, diagnosed with psychotic disorder and dementia, was also inaccurately coded in the MDS as not having a serious mental illness, even though his PASRR Level 1 screening was positive for mental illness. Resident #53, with psychotic disorder and major depressive disorder, was incorrectly coded in the MDS as not having a serious mental illness, despite his PASRR Level 1 screening indicating a primary diagnosis of dementia. The MDS Coordinator, during an interview, revealed a misunderstanding of the coding requirements for Section A1500 of the MDS, which led to these inaccuracies. She believed that if residents did not qualify for specialized services under PASRR, they should be coded as negative for mental illness, intellectual disability, or developmental disability, even if they had a positive PASRR screening. This misunderstanding resulted in the incorrect coding of the residents' mental health status, potentially affecting their care and services.
Failure to Follow G-Tube Medication Administration Policy
Penalty
Summary
The facility failed to ensure that a resident with an enteral device received appropriate treatment and services to prevent complications. The resident, a female with intact cognition, had a gastrostomy tube (G-Tube) due to conditions including pharyngeal dysphagia and erosive esophagitis. The care plan indicated she was on a pureed diet with liquid feedings via the G-Tube as needed, but it lacked specific instructions for administering medications through the G-Tube. During an observation, LVN D prepared the resident's morning medications by crushing them together, contrary to the facility's policy, which required medications to be administered separately with water flushes before, between, and after each medication. LVN D used a syringe plunger to push the medication mixture into the G-Tube, which led to a blockage. He attempted to resolve the blockage by dislodging the medication and re-crushing it, but he did not flush the G-Tube with water before or after administering the medications. Interviews with LVN D and the MDS Nurse Coordinator revealed that the facility's policy was not followed. LVN D admitted to not following the correct procedure due to concerns about the resident's tolerance for extra water flushes and acknowledged the risk of tube occlusion and damage. The facility's policy outlined specific steps for safe medication administration through an enteral tube, which were not adhered to, potentially placing the resident at risk for complications.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the accurate administration of medications for two residents, leading to potential risks. Resident #34, who had a gastrostomy tube due to pharyngeal dysphagia, received medications that were improperly crushed and administered together without the required water flushes before and after each medication. The Licensed Vocational Nurse (LVN) responsible for administering the medications did not follow the physician's orders or the facility's policy, which required medications to be given separately with water flushes in between. The LVN admitted to crushing all medications together due to concerns about the resident's tolerance for extra water flushes, despite knowing that Protonix should not be crushed and required specific administration instructions. Resident #50, who had severe cognitive impairment and a diagnosis of Alzheimer's Disease, did not receive the prescribed Cyanocobalamin (Vitamin B12) 2500 mcg tablet due to its unavailability. Instead, a Medication Aide (MA) performed unauthorized mathematical calculations to substitute the dose with available Vitamin B12 tablets of different strengths. The MA administered two 1000 mcg tablets and one 500 mcg tablet to meet the prescribed dose but documented it as a single 2500 mcg tablet. The Assistant Director of Nursing (ADON) acknowledged that the physician's order should have been updated to reflect the available medication strengths and that medication aides were not permitted to perform dose calculations. The facility's policies on administering medications through an enteral tube and general medication administration were not adhered to, resulting in potential risks for non-therapeutic responses and incorrect dosing. The deficiencies in medication administration practices were identified through observations, interviews, and record reviews, highlighting the need for accurate physician orders and adherence to established protocols to ensure resident safety.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 7% due to two errors out of 26 opportunities. The deficiency involved a resident who was administered medications via a gastrostomy tube. The Licensed Vocational Nurse (LVN) responsible for the administration crushed a delayed-release medication, Protonix, which is not intended to be crushed, and mixed it with other medications before administering them together. This action was contrary to the physician's orders and the facility's policy, which required the use of Protonix granules and separate administration of medications with flushing in between. The resident involved was an elderly female with intact cognition, who had a gastrostomy tube due to conditions including pharyngeal dysphagia and erosive esophagitis. The LVN admitted to substituting the prescribed Protonix granules with a tablet form due to unavailability in the medication cart and acknowledged the error of crushing the tablet. The Assistant Director of Nursing (ADON) confirmed that the LVN did not adhere to the facility's medication administration policies, which prohibit crushing delayed-release medications and require separate administration through enteral tubes.
Failure to Accurately Document Resident's Code Status
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented, specifically regarding the resident's code status. The resident, an elderly female with Alzheimer's Disease, depression, coronary atherosclerosis, communication deficit, and a history of colon cancer, was admitted with a Full Code status. However, a signed and notarized Out Of Hospital Do Not Resuscitate (OOHDNR) document was found in her chart, indicating a discrepancy between her documented code status and her actual wishes. Interviews with facility staff revealed confusion and lack of communication regarding the resident's code status. A Licensed Vocational Nurse (LVN) and an unidentified Registered Nurse (RN) both believed the resident was Full Code based on the face sheet and physician orders. The Admission Coordinator also confirmed the Full Code status but acknowledged that the resident's family had been indecisive about the code status. The facility's Administrator noted that the hospice service had not communicated the change in code status to the facility, leading to the OOHDNR document being filed without proper notification or updates to the resident's medical records. The facility's policy on advance directives requires that changes be submitted in writing to the Administrator and communicated to the Care Plan team. However, the OOHDNR document was faxed to the facility and placed in a tray for scanning without anyone being made aware of the change. This oversight could have resulted in the resident receiving resuscitation against her wishes, as staff would have attempted to resuscitate her based on the incorrect Full Code status documented in the facility's records.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN D, who did not adhere to the required Enhanced Barrier Precautions (EBP) when administering medications through a gastrostomy tube to a resident. The resident, a female with multiple medical conditions including pharyngeal dysphagia, necrotizing fasciitis of the neck, and a gastrostomy tube, was observed to have a sign on her room indicating the need for EBP, which includes wearing gloves and a gown for high-contact activities. Despite this, LVN D only donned gloves and failed to wear a gown, which is a breach of the facility's policy and CDC guidelines aimed at preventing the spread of infections. Interviews with the ADON and the MDS Coordinator, who also serves as the Infection Preventionist, confirmed that the facility's policy requires the use of gloves and gowns for residents with indwelling medical devices, such as feeding tubes, to reduce infection risks. LVN D admitted to not wearing a gown, mistakenly believing it was unnecessary since the resident no longer had an active infection or pressure ulcer. This oversight in following the established infection control protocols could potentially expose residents to communicable diseases and infections.
Facility Fails to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect several residents from abuse and neglect, as evidenced by multiple incidents involving both staff and other residents. One incident involved a resident who reported being physically assaulted by a medication aide (MA). The resident, who was cognitively intact, claimed that the MA grabbed her arm and refused to let go, resulting in bruising. Despite the resident's report and a subsequent hospital evaluation confirming the assault, the facility did not properly investigate or report the incident, nor did they suspend the alleged perpetrator. Another deficiency involved a resident who was left unsupervised for several hours during the night, resulting in her falling out of bed and remaining on the floor for approximately 4.5 hours. The certified nursing assistant (CNA) responsible for checking on the resident falsely reported having completed rounds, leading to the resident's prolonged neglect. The family, who had cameras in the resident's room, was aware of the incident, and the CNA was later terminated for neglect. Additionally, the facility failed to prevent abuse between residents. One resident, with a history of aggressive behavior, was involved in multiple incidents of physical aggression towards other residents, including pushing, choking, and inappropriate sexual behavior. Despite these repeated incidents, the facility did not adequately address the resident's behavior or implement effective interventions to prevent further occurrences. This lack of action resulted in continued abuse and potential harm to other residents.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its abuse policy, resulting in multiple incidents of abuse and neglect involving several residents. One resident reported being physically assaulted by a staff member, but the facility did not investigate the allegation or suspend the alleged perpetrator. The resident was cognitively intact and had a history of confrontational behavior related to smoking. Despite the resident's report of bruising consistent with her account of the incident, the facility did not take appropriate action to protect her or report the incident to the state agency until prompted by surveyor intervention. Another resident was left unattended for several hours during the night, resulting in her rolling out of bed and remaining on the floor for an extended period. The CNA responsible for her care falsely reported having checked on the resident, and the incident was only discovered due to the presence of cameras in the resident's room. This neglect was confirmed, and the CNA was terminated, but the facility's failure to ensure adequate supervision and care for the resident was a significant deficiency. Additionally, the facility failed to protect residents from abuse by other residents. One resident was found inappropriately touching another resident, and there were multiple incidents of physical aggression involving the same resident. These incidents were not properly investigated, and the facility did not implement measures to prevent further occurrences. The lack of appropriate interventions and reporting of these incidents highlights the facility's failure to maintain a safe environment for its residents.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices during a mechanical lift transfer for a resident, leading to an accident. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs), fell during a transfer conducted by a CNA who was working alone. The resident's care plan required the use of a mechanical lift with two staff members for transfers due to his condition, which included paralysis on the left side from a stroke and generalized muscle weakness. On the day of the incident, the CNA attempted to transfer the resident alone using a Hoyer lift, contrary to the facility's protocol that mandates two staff members for such transfers. During the transfer, a strap from the Hoyer lift came off, causing the resident to fall to the floor and sustain a laceration and bruising to the right eye area. The CNA admitted to not asking for assistance and acknowledged that she had previously transferred the resident unassisted without incident. Interviews with facility staff revealed that the Hoyer lift used was relatively new and had smaller hook holders, which were deemed inappropriate after the incident. The Maintenance Supervisor and Therapy Director confirmed that the lift was removed from use following the accident. The facility did not have a schedule for checking the Hoyer lifts, and the CNA involved was terminated for failing to meet performance expectations by not adhering to the two-person transfer protocol.
Failure to Secure Resident During Transportation
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation, leading to an accident. The resident, a female with multiple medical conditions including double lower extremity amputation and cognitive impairment, was being transported from the hospital in a manual wheelchair. The transportation driver did not secure the wheelchair properly, resulting in the resident sliding out of the wheelchair onto the floor of the van. The incident occurred as the van was nearing the facility, and the resident was found on the floor with a pillow under her head, experiencing pain in her hips. The transportation driver, who was not a CNA, was not trained on how to handle such incidents and did not call emergency services immediately. Instead, she attempted to secure the resident on the floor of the van and continued the journey back to the facility. Upon arrival, facility staff assessed the resident and called emergency medical services, who transported the resident to the hospital for further evaluation. The driver had previously received training on proper wheelchair securement and transportation procedures but failed to apply this knowledge during the incident. Interviews with facility staff revealed that the resident typically used a power wheelchair but was in a manual wheelchair on the day of the incident. The Director of Nursing and Assistant Administrator acknowledged that the resident's care plan should have addressed the risk of sliding out of the wheelchair, and additional personnel should have been present during transportation. The facility's transportation policy required immediate reporting of incidents, but this protocol was not followed by the transportation driver.
Failure to Account for Controlled Medication
Penalty
Summary
The facility failed to maintain accurate records and control of a resident's controlled medication, Hydrocodone, which was prescribed for pain management. The resident, a female with a history of orthopedic aftercare following surgical amputation and peripheral vascular disorder, was readmitted to the facility with a prescription for Hydrocodone. The medication was delivered to the facility, but the staff could not account for it, leading to a deficiency in pharmaceutical services. Interviews and record reviews revealed that the Hydrocodone was delivered on a specific date, signed for by an LVN, and placed in the medication cart. However, the medication was not located afterward, and there was no record of its administration or destruction. The facility's Director of Nursing (DON) and other staff members were unaware of the missing medication until it was brought to their attention during the survey. The lack of proper documentation and control over the medication could have resulted in the resident not receiving the intended therapeutic dose for pain management. The facility's policies on medication storage and destruction were not followed, as evidenced by the missing Hydrocodone and the absence of a control drug record. The DON acknowledged that missing medication is a reportable incident and expressed an intention to in-service staff on narcotic delivery procedures. Despite the facility's policy requiring secure storage and restricted access to controlled substances, the medication was not accounted for, highlighting a significant lapse in the facility's pharmaceutical services.
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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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