Coral Rehabilitation And Nursing Of Austin
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Texas.
- Location
- 6909 Burnet Ln, Austin, Texas 78757
- CMS Provider Number
- 455862
- Inspections on file
- 60
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 53 (10 serious)
Citation history
Health deficiencies cited at Coral Rehabilitation And Nursing Of Austin during CMS and state inspections, most recent first.
The facility failed to ensure that grievances raised in Resident Council meetings were properly forwarded, reviewed, and answered in writing. Resident Council minutes showed repeated concerns about staff introducing themselves and call light response times, but the Activities Director did not consistently provide these grievances to the designated Grievance Official. The QA Director reported not receiving Resident Council grievances for an unknown period, and the Resident Council President stated that grievances were repeatedly brought up without evidence of resolution. Requested grievance records for the period reviewed were not provided, despite facility policies requiring review, written responses, and documentation of actions taken.
The facility failed to honor residents’ rights to manage their personal funds by not providing timely access to trust fund money, especially on weekends, and by not issuing accurate balance statements. A cognitively intact resident reported never receiving a statement and being unable to obtain the full amount needed to pay a phone bill, while two other residents reported not receiving their full monthly $75 allotments when requested, limiting their ability to purchase food and other items. Staff acknowledged that no one was available on weekends to disburse funds, that trust fund records were inaccurate and could not be reliably printed, and that there was no accessible trust fund policy despite a form stating that withdrawals must be documented and quarterly statements provided.
The facility failed to provide required quarterly written statements and maintain accurate records for resident trust fund accounts. A resident with intact cognition and mental health diagnoses reported never receiving a balance statement, not knowing her account balance, and only receiving partial funds when requesting money for bills, with no access to funds on weekends. Two other residents with cognitive communication deficits and cognitive impairment stated they were supposed to receive $75 monthly but were not given the full amount when requested, limiting their ability to purchase food. The ADM and a director confirmed the facility had not been keeping records of personal funds, including quarterly statements and withdrawals, and could not produce accurate trust fund statements or documentation of disbursements, despite a policy requiring documentation of all transactions and quarterly statements.
The facility failed to properly recognize, document, and route grievances related to unresolved concerns raised in resident council meetings and complaints about access to personal trust fund money. A cognitively intact resident council officer reported that grievances were repeatedly discussed in council meetings without resolution, and the Activities Director admitted she did not forward these council grievances to the designated Grievance Official. Another resident with severe cognitive impairment reported not receiving the full monthly amount of personal funds she was supposed to get, stating the facility said it would "run out" of money, and she had complained at the receptionist desk. Several staff, including the DON and other department heads, acknowledged that complaints about missing or delayed trust fund money could be grievances, yet no grievance forms were completed, and no grievance records were produced for the period reviewed, contrary to facility grievance and resident council policies.
The facility did not provide RN coverage for at least 8 consecutive hours on multiple days, despite a census of dozens of residents and a written policy requiring an RN on duty daily. Timecard records showed no RN worked on several specific dates, and interviews with HR, the DON, the ADM, and a director confirmed that staffing processes and meetings did not prevent these gaps. Staff acknowledged that an RN is required 8 hours per day for regulatory compliance, leadership, and to perform functions that LVNs cannot, and reported ongoing difficulty hiring additional RNs, including a weekend RN supervisor.
A facility licensed for 157 beds failed to employ a qualified full-time social worker over several months, despite regulatory requirements for facilities with more than 120 beds. Review of the facility summary and staff roster confirmed there was no social worker on staff, and there was no specific policy for a social worker, only a general acknowledgment that one was required. The QA Director reported that the prior social worker left and that she had been performing social services duties since then, believing this met the requirement as she had a similar degree, even though she did not hold the social worker title. The ADM and Director of Special Projects acknowledged the need for a social worker to address residents' psychosocial and related service needs, such as podiatry, dental, and vision, while asserting that resident care had not been negatively affected because the QA Director was covering these functions.
Surveyors found that care plans were not revised after significant incidents for two residents. One resident with multiple chronic conditions and moderately impaired cognition experienced a witnessed fall during a supervised smoke break, but this event was not added to the existing fall care plan. Another resident with communication and cognitive deficits, who had documented physical and verbal behaviors, was involved in a verbal/physical altercation requiring staff intervention, yet the care plan was not updated to reflect this aggression. The DON confirmed that these care plans were not revised after the incidents, despite facility policy requiring care plans to be reviewed and revised when new problems or goals are identified.
A resident with severe cognitive impairment and a history of strokes eloped from the facility after staff failed to monitor an exit door during an EMS response. The door's alarm system was not functioning, and staff were unaware of the malfunction. The resident was missing for several days before being found by law enforcement, during which time she was exposed to cold weather and missed her medications. The facility did not follow its elopement prevention policies, and the responsible party was not notified immediately.
A resident with severe cognitive impairment eloped from the facility and was not located for several days. Although staff notified law enforcement, the administrator, and family, the resident's court-appointed guardian was not immediately informed as required by policy. Interviews and records showed confusion among staff about notification responsibilities, resulting in a significant delay before the guardian was contacted.
A resident with chronic obstructive pulmonary disease and other conditions was using a CPAP machine as documented in care plans, progress notes, and hospital discharge summaries, but there was no corresponding physician order in the medical record. Nursing staff confirmed the resident's use of the CPAP machine, and the device was observed at the bedside, but the required physician order was not present as per facility policy.
A resident with multiple mobility and cognitive diagnoses experienced an unwitnessed fall resulting in injury, but the nursing staff did not notify the physician or family as required by facility policy. The resident was later found unresponsive and died after hospital transfer. Documentation of notification and neurological checks was incomplete, and interviews confirmed that required notifications were not made.
A resident with mobility and cognitive needs suffered an unwitnessed fall with a head injury, after which nursing staff failed to complete required neuro checks, notify the physician and family, and follow post-fall protocols. Incomplete documentation and lack of communication led to the resident being found unresponsive the next morning and passing away, with staff interviews revealing gaps in training and protocol adherence.
A resident with mobility and cognitive challenges experienced an unwitnessed fall resulting in head injury, but nursing staff failed to complete required neuro checks, post-fall assessments, and timely notifications to family and physician. The nurse involved lacked knowledge of fall protocols and EMR documentation, and the incident was not properly communicated or documented, leading to incomplete monitoring and a fatal outcome.
A resident with severe cognitive impairment and multiple comorbidities was found with a significant bruise and later diagnosed with an acute femur fracture of unknown origin. Despite staff recognizing the injury as unexplained and facility policy requiring prompt investigation, no investigation was initiated or completed to determine the cause of the injury.
A cognitively impaired resident with multiple risk factors for falls and requiring two-person assistance was not properly monitored or assisted during transfers, resulting in an unwitnessed injury and acute femoral fracture. Staff failed to follow fall protocols, did not complete required assessments, and inconsistently used the care plan or EMR to determine transfer needs, leading to a deficiency in accident prevention and supervision.
A resident with severe cognitive impairment and multiple comorbidities was found with a bruise and later diagnosed with an acute femur fracture of unknown origin. Despite staff recognizing the injury as suspicious and knowing the requirement to report such incidents, the event was not reported to the SSA within the mandated timeframe. Interviews confirmed that staff were aware of the policy but did not follow it, and there was no recent staff training on reporting injuries of unknown origin.
A resident with a tracheostomy did not have physician orders for trach care or suctioning, and nursing staff did not perform regular care, instead allowing the resident to manage his own trach without supervision or competency validation. The resident reused disposable cannulas and was later hospitalized with pneumonia. Another resident received trach care that did not follow infection control protocols, and multiple nurses reported inadequate training and lack of competency checks. These failures were identified as Immediate Jeopardy due to the risk of infection and respiratory complications.
A resident with chronic pain and complex medical needs was left without Hydrocodone due to the facility's failure to reorder the medication in time, resulting in severe, unrelieved pain and repeated requests for hospital transfer. Documentation discrepancies between the MAR and narcotic count sheet, as well as lack of follow-up pain assessments after PRN administration, were also identified. Nursing staff and providers were not notified promptly about the medication shortage, and facility policies for pain management and documentation were not followed.
A resident with a tracheostomy did not receive care according to professional standards, as observed when a nurse failed to perform hand hygiene, used non-sterile equipment, and did not follow required procedures for suctioning and oxygenation. Multiple nurses reported inadequate training and lack of competency validation for trach care, and the facility could not provide documentation of staff competencies. These failures led to an Immediate Jeopardy situation due to the inability of staff to safely care for residents with tracheostomies.
The facility did not provide two residents and their representatives with written notification of facility-initiated discharges, including reasons for the move, appeal rights, or Ombudsman contact information. Instead, families were informed by phone on the day of discharge or after the fact, with no written notice or options for alternative placements, and the required notifications to the Ombudsman were not made.
Two residents with pressure ulcers did not receive physician-ordered wound care on multiple days, and the facility failed to maintain complete and accurate medical records documenting these treatments. Staff interviews revealed confusion about responsibility for wound care in the absence of the wound nurse, leading to missed treatments and incomplete documentation.
A nurse failed to perform proper hand hygiene and did not use sterile technique while providing tracheostomy care and suctioning for a resident with complex medical needs, including respiratory failure and a tracheostomy. The nurse did not sanitize hands before and after glove changes, used non-sterile equipment, and did not follow facility policies for infection prevention, as confirmed by staff interviews and policy review.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
The facility did not ensure that a resident with a colostomy had physician orders for its management, nor did it have orders specifying the dialysis schedule for two residents receiving regular hemodialysis. Staff interviews confirmed that these orders were expected but not present, which could result in missed care.
Several residents with open wounds and indwelling catheters did not have required PPE signage or supplies at their doors, and staff—including an ADON—were observed providing high-contact care without wearing gowns or following proper hand hygiene. Staff interviews revealed a lack of understanding about Enhanced Barrier Precautions, and the facility could not provide current hand hygiene or EBP policies when requested.
A resident with neurogenic bladder and an order for an indwelling foley catheter experienced a delay of over eight hours in catheter reinsertion after it was found to have come out. Despite the resident's repeated requests and staff awareness, the RN postponed the procedure, causing the resident discomfort and distress. The facility was unable to provide a catheter care policy when requested.
A resident with a history of stroke, dementia, and chronic pain experienced a significant decline, including staying in bed, inability to self-feed, and leg pain, over several days. Staff observed these changes but did not promptly notify the NP or responsible party, nor document the decline, resulting in delayed medical intervention. The resident was later hospitalized with aspiration pneumonia, UTI, and a femur fracture, and the facility was cited for failing to follow notification protocols.
A resident with a history of stroke, dementia, and chronic pain experienced a significant decline, including lethargy, inability to feed himself, and leg pain, which staff observed but did not promptly report or document. The lack of timely recognition and escalation led to delayed medical intervention, and the resident was later hospitalized with aspiration pneumonia, UTI, and a femur fracture. The facility did not follow its policy for notifying the physician and responsible party of significant changes in condition.
The facility did not maintain required indoor temperatures, resulting in several residents experiencing excessive heat in their rooms for extended periods. Despite multiple complaints and requests for fans or air conditioning, not all residents received relief, and temperature monitoring and documentation were inconsistent. Residents with conditions such as COPD, diabetes, and heart failure were affected, and staff interviews confirmed delays in addressing the air conditioning failures.
A resident with bipolar disorder and a history of aggression did not receive timely psychiatric evaluation or behavioral health interventions despite repeated physician orders and escalating behaviors, resulting in an altercation where another resident was injured. Staff and documentation confirmed ongoing behavioral issues and delays in psychiatric care, with inadequate monitoring and follow-up for both the resident exhibiting aggression and the resident who was harmed.
Two residents were involved in an incident where one pushed another's walker, resulting in a fall and a significant skin tear. Although the event was documented and reported internally to the DON and NP, it was not reported to the State Survey Agency as required by facility policy, due to the administrator's belief that there was no malicious intent. Both residents had complex medical and behavioral histories, and the failure to report the incident constituted a deficiency in abuse reporting protocols.
A resident with multiple medical and psychiatric diagnoses missed several doses of prescribed medications while out on pass, and staff failed to notify the physician or NP as required. Interviews and record review showed inconsistent practices and lack of documentation regarding provider notification, despite facility policy mandating prompt communication of missed medications.
A resident with multiple chronic conditions missed several doses of prescribed medications while out on pass, and staff failed to consistently notify the NP or physician or document these missed doses as required by facility policy. This resulted in a breakdown of pharmaceutical services and a deficiency in medication administration procedures.
Three residents did not receive timely dental care, including exams, denture placement, and cleanings, despite physician orders and care plan indications. Staff interviews revealed confusion about referral responsibilities, and the social worker had only recently arranged a new dental contract, with no dental visits yet scheduled. Facility policy required social services to assist with dental appointments, but documentation and follow-through were lacking.
A resident with multiple medical and psychiatric diagnoses experienced several falls that were documented in incident reports, but these events were not reflected in the resident's care plan. Staff interviews confirmed that falls should have been included in the care plan and that it is the responsibility of various team members to ensure updates. The facility's policy requires care plans to be comprehensive and revised as conditions change, but this was not followed, resulting in a deficiency.
Two residents experienced unsafe conditions due to inadequate wheelchair maintenance. One resident's wheelchair, which was from the 1960s, had a loose lock, posing a risk during transfers. Another resident's wheelchair brakes were not functioning, leading to a potential fall risk. Despite work orders and staff awareness, repairs were not completed timely, violating facility policies on maintenance and resident safety.
The facility failed to maintain resident dignity and privacy in two incidents. A CNA was observed using his phone during peri care for a resident with dementia, leaving her exposed. Another resident with a catheter was seen without a privacy bag, contrary to facility policy. Both incidents highlight lapses in respecting resident rights.
A resident receiving enteral nutrition through a gastrostomy tube was left lying flat, contrary to her care plan and facility policy, which required her head of bed to be elevated at least 30 degrees to prevent aspiration. The oversight was discovered by the resident's family member, who found her struggling to breathe with foam around her mouth. The family member intervened by elevating the bed, which alleviated the resident's breathing difficulties. Interviews with staff revealed a lack of communication and awareness regarding the incident.
The facility failed to develop baseline care plans within 48 hours for several newly admitted residents, who had various medical conditions. This deficiency was due to a backlog in care plans caused by recent management changes and staffing shortages, leading to potential miscommunication and inadequate care.
The facility failed to develop comprehensive care plans for three residents, despite their medical needs and cognitive status. Interviews with staff revealed a backlog in care plans due to management changes and staffing issues, leading to potential miscommunication and inadequate care. The facility's policy requires a baseline care plan within 48 hours and a comprehensive plan within seven days, which were not met.
A resident was left exposed during a change when a CNA failed to close the door and pull the privacy curtain, despite being trained on resident rights. The resident, who required substantial assistance, was cognitively intact and had multiple health conditions. Interviews with the CNA, DON, and ADM confirmed the lapse in privacy, which is against the facility's dignity policy.
A resident with multiple health issues was found lying in bed with soiled sheets due to spilled coffee. Despite being dependent on staff for bed mobility, the sheets were not changed promptly, as required by facility policy. Interviews with staff revealed a lack of adherence to procedures for changing soiled bedding, potentially risking the resident's skin integrity and comfort.
A resident experienced a significant weight loss of 25.38% over six months due to the facility's failure to maintain acceptable nutritional status. Despite having diabetes and feeding difficulties, the resident's care plan did not address potential weight loss, and there was a lack of timely intervention. Communication and monitoring breakdowns among staff contributed to the oversight, as the RD relied on information from the DM and did not verify weight loss data independently.
A resident with a history of stroke and diabetes developed a skin tear that was not properly assessed or treated according to the care plan, leading to an infection. The facility missed several wound care treatments and failed to conduct weekly skin assessments, resulting in the need for antibiotics. Staff interviews revealed communication and documentation issues regarding the resident's wound care.
A resident was discharged from the facility without receiving a written notice of discharge, and the Ombudsman was not informed. The resident, who had a BIMS score indicating cognitive intactness, left the facility without oxygen and refused to sign an AMA form. Despite this, the facility discharged the resident without following proper procedures, leading to distress and confusion. Interviews with staff revealed a lack of adherence to discharge protocols, and the facility's discharge guidelines were not followed.
A resident with multiple medical conditions and moderate cognitive impairment was discharged without proper documentation or preparation, violating the facility's discharge policy. The resident was left at home without family present, and there was no documented communication about discharge plans or home health services. Facility staff admitted to not following the discharge policy, risking the resident's safety and care.
A facility failed to implement its abuse prevention policies when a resident's rape allegation was not reported to authorities or investigated properly. The resident, with a history of mental health issues, claimed abuse, but the facility did not notify the police or conduct a thorough investigation, placing residents at risk.
A resident with a history of making false allegations reported being raped multiple times, but the facility failed to investigate or report these claims as required by policy. The Administrator did not document the investigation or inform the resident's representative, and relevant staff and authorities were not notified. This led to an Immediate Jeopardy situation due to the risk of undetected abuse.
Three residents experienced unsafe and inconvenient room conditions due to the placement of air conditioning units and cords obstructing closet access. A resident with Paralytic syndrome struggled to move a portable unit blocking her closet, while another resident had to unplug an air conditioner cord to access her closet, causing the room to warm. A third resident, at high risk for falls, faced a trip hazard from a cord draped across his closet door. Staff interviews confirmed the unsafe setup.
A facility failed to provide necessary ADL assistance for three residents, leading to deficiencies in nutrition and hygiene. A resident, who is blind, was left without meal assistance, causing frustration and neglect. Two other residents did not receive regular showers as per their care plans, impacting their personal hygiene. The facility's policies on meal assistance and hygiene were not effectively implemented, resulting in unmet needs and potential emotional distress.
Failure to Address and Respond to Resident Council Grievances
Penalty
Summary
The deficiency involves the facility’s failure to ensure prompt efforts to resolve grievances raised through the Resident Council and to provide written responses to those grievances. Resident Council minutes for February 2026 and March 2026 documented repeat concerns from residents about staff introducing themselves and call light response times. The facility’s Resident Council policy required that concerns, grievances, and recommendations discussed in meetings be documented, that all written concerns be reviewed, that a written response be provided, and that documentation of actions taken be maintained. The facility’s Grievances Policy further specified that the Administrator designates a Grievance Official responsible for receiving and tracking grievances, conducting investigations, maintaining documentation, and ensuring written responses. Interviews with facility staff and the Resident Council President showed that grievances from Resident Council meetings were not being forwarded to or addressed by the designated Grievance Official. The Quality Assurance Director, who oversaw grievances, stated that the Activities Director had not been providing her with grievances from Resident Council for an unknown period of time, despite Resident Council meetings being a source of grievances and resident concerns. The Activities Director acknowledged receiving grievances from Resident Council and admitted she had not given the grievances from at least one Resident Council meeting to the Quality Assurance Director. The Resident Council President reported that grievances appeared not to be answered, as the same concerns were repeated at each meeting and the council had not heard of any grievances being resolved recently. When records of grievances since January 2026 were requested from the Quality Assurance Director, they were not provided.
Failure to Provide Timely Access and Accurate Accounting of Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to manage their personal financial affairs and to provide timely access to their funds. Three residents with facility-managed trust funds reported not receiving full access to their money upon request and not receiving balance statements. One cognitively intact female resident with major depressive disorder and generalized anxiety disorder stated she had a trust fund but had never been given a statement and did not know her balance. She reported having to ask for money to pay her phone bill and only receiving whatever amount staff said was available, and that she could not request money on weekends. A male resident with moderate cognitive impairment and major depressive disorder reported he was supposed to receive $75 per month but did not receive the full amount at once despite asking, which affected his ability to buy outside food. Another female resident with severe cognitive impairment and a cognitive communication deficit reported she was also supposed to receive $75 per month, but the facility would not give her the full amount when requested because the facility would “run out,” and she used extra money to pay for food. Staff interviews and record review further showed systemic issues with management of resident trust funds. The receptionist stated that residents with trust funds received money through the facility but confirmed that no one was available on weekends to provide residents with their funds. The Administrator and Director of Special Projects acknowledged that residents were not being given their money in a timely manner and emphasized the importance of keeping records of residents’ personal funds, including quarterly statements and withdrawals. The Director of Special Projects reported they could not print trust fund statements because the records would be incorrect and that the facility was not keeping accurate records of trust fund transactions, leaving them without evidence of money disbursements. Although a “Resident Trust Account Authorization Form” referenced quarterly written statements and documentation of withdrawals, the facility was unable to produce a trust fund policy when requested, stating they could not locate one.
Failure to Provide Quarterly Trust Fund Statements and Maintain Accurate Personal Funds Records
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and document residents’ personal trust funds, including not providing required quarterly written statements for three residents with accounts held by the facility. One cognitively intact resident with major depressive disorder and generalized anxiety disorder reported having a trust fund but stated she never received a balance statement and did not know how much money she had, suggesting this had been occurring since the prior year. She reported having to ask the facility for money to pay her phone bill and only receiving whatever amount staff said was available, without being able to obtain the full amount requested, and stated she could not request money on weekends. Two other residents with cognitive communication deficits and varying levels of cognitive impairment reported they were supposed to receive $75 per month but were not given the full amount when requested. One resident stated he did not receive the full $75 at once despite asking, which affected his ability to buy outside food. Another resident stated she was supposed to get $75 per month, but the facility would not give her the full amount because the facility would “run out,” and she used extra money to pay for food. In an interview, the Administrator and Director of Special Projects acknowledged the facility had not been keeping records of residents’ personal funds, including quarterly statements and withdrawals, and that they could not print accurate trust fund statements or provide evidence of money disbursements because trust fund transactions were not being accurately recorded, contrary to the facility’s written policy requiring documentation of all withdrawals and provision of quarterly written statements.
Failure to Process and Address Resident Grievances and Trust Fund Complaints
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances without discrimination or reprisal and to ensure grievances were properly identified, documented, and routed to the Grievance Official for follow-up. Resident #1, a cognitively intact female with major depressive disorder and generalized anxiety disorder, served as vice president of the resident council and reported that grievances were repeatedly brought up at resident council meetings without being answered, and that the council had not heard of any grievances being resolved recently. The Activities Director acknowledged receiving grievances from resident council, including those from March 2025, but admitted she had not forwarded these grievances to the designated Grievance Official, despite facility policy requiring documentation, review, written response, and maintenance of actions taken for resident council concerns. The facility also failed to treat residents’ complaints about not receiving their personal funds from trust accounts as grievances and to process them through the grievance system. Resident #3, a female with severe cognitive impairment (BIMS score 6/15) and a diagnosis including cognitive communication deficit, stated she was supposed to receive $75 per month but was not given the full amount when requested because the facility “would run out,” and that she had complained at the receptionist desk. Multiple staff, including the Director of Special Projects, DON, Medical Records/Central Supply personnel, and the Quality Assurance Director, acknowledged that residents’ complaints about not receiving their money could or did constitute grievances, yet no grievance forms were completed for these concerns. The DON reported hearing about residents not receiving their money during her first weeks at the facility in January 2026 and believed the former administrator was addressing the issue, but she did not write any grievances related to residents’ trust fund money. The Medical Records/Central Supply staff member confirmed residents had been asking for their money but could not receive the full amount because the facility did not have the funds, and she recognized this as a grievance but assumed it was already being worked on. The Quality Assurance Director, designated as the Grievance Official, stated she oversaw grievances, ensured they were given to the appropriate person, and followed up within three days, but she had not received grievances from resident council and was unaware that residents had concerns about not receiving their money. When surveyors requested records of grievances since January 2026, none were provided, despite facility policies outlining requirements for documenting and responding to grievances and resident council concerns.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) were provided for at least 8 consecutive hours per day, 7 days a week, as required by regulation and the facility’s own Nursing Services Policy. Review of the Raw Punch Report for the period 03/01/2024 to 04/01/2024 showed there was no RN working on 03/01/2026, 03/05/2026, 03/28/2026, and 03/29/2026, despite a resident census of 74 residents on 04/01/2026. The facility’s written policy, revised 01/2026, stated that an RN will be on duty at least 8 consecutive hours per day, 7 days per week. During interviews, the HR staff member reported participating in staffing meetings with the staffing coordinator, administrator (ADM), and director of nursing (DON) to ensure RN coverage but stated she was unaware that the facility lacked an RN on the identified dates. She stated it was important to have an RN staffed 8 hours a day every day to ensure quality assurance and noted the facility had been unable to hire additional RNs, including a weekend RN supervisor. The DON stated she was available on call 24/7 and acknowledged it was important to staff an RN 8 hours a day because it was a state requirement, and reported there had been nothing that affected business operations, resident care, or psychological changes in residents. The ADM and Director of Special Projects stated the expectation was to have an RN 8 hours a day, emphasized the importance of leadership and that RNs can perform tasks LVNs cannot, and confirmed they were in the process of finding more RNs.
Failure to Employ Required Full-Time Social Worker for 157-Bed Facility
Penalty
Summary
The facility, licensed for 157 beds, failed to employ a qualified full-time social worker from January 2026 to April 2026, despite the regulatory requirement for a full-time social worker in facilities with more than 120 beds. Review of the Facility Summary Report confirmed the licensed capacity of 157 beds, and review of the undated staff roster showed there was no social worker employed at the facility during this period. The facility also did not have a policy specific to a social worker, although leadership acknowledged it was a general requirement to have one. During interviews, the Quality Assurance Director stated that the previous social worker had left around November 2025 and that she had been performing social services for residents since that time. She believed that as long as someone with a similar degree was performing social services, the facility met the requirement for having a social worker, even if that person did not use the title of social worker. The ADM and Director of Special Projects acknowledged that a social worker was needed for the number of beds in the facility and that it was important to have a social worker to meet residents' needs, including arranging podiatry, dental, and vision services. They stated there was no negative effect on resident care because the Quality Assurance Director was performing social worker duties after the prior social worker left, and they reported they were attempting to contact the former social worker and were actively seeking to hire a replacement.
Failure to Update Care Plans After Falls and Behavioral Incidents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure comprehensive care plans were reviewed and revised by an interdisciplinary team after each assessment and after acute incidents. For one resident with Type 2 diabetes, Crohn’s disease, asthma, dementia, major depressive disorder, and hypertension, the quarterly MDS dated 2/26/26 showed moderately impaired cognition and a need for supervision when walking up to 50 feet. The resident’s care plan documented a prior fall on 11/25/25 but contained no additional falls. However, progress notes and the facility’s incident log showed the resident sustained a witnessed fall on 1/22/26 during a supervised smoke break when another resident pushed her while reaching for a cigarette butt, and this fall was not added to or reflected in the care plan. A second resident, admitted with aphasia, memory deficit, cognitive social or emotional deficit, and cognitive communication deficit, had a comprehensive MDS dated 2/27/26 indicating intact cognition and documented physical and verbal behaviors toward others. The resident’s care plan identified a potential to demonstrate physical behaviors related to anger and poor impulse control, but there were no updates following an incident on 2/13/26. Progress notes and the incident log documented that staff had to intervene and separate this resident from another resident due to verbal/physical aggression on that date, yet the care plan was not revised to reflect this event. During interview, the DON acknowledged that the care plans for both residents had not been updated after these incidents and stated that the MDS nurse was responsible for updating care plans after acute incidents, and that care plans are expected to be reviewed and revised when new problems or goals are identified per facility policy.
Failure to Prevent Resident Elopement Due to Unmonitored Exit and Non-Functioning Door Alarm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of strokes, and impaired safety awareness eloped from the facility. The resident was able to exit through a door in Unit 3 vicinity hall 100, which was not properly monitored or secured during an EMS response for another resident's medical emergency. The door's 15-second delay alarm system was not functioning correctly, and staff were unaware of the malfunction. The resident was last seen in her room by staff and was later found missing during routine rounds. The facility's records indicated that the resident was considered low risk for elopement, and there was no prior evidence of exit-seeking behavior, but she had a history of confusion and required redirection when wandering into previous rooms. Staff interviews revealed that during the time of the emergency involving another resident, the exit door used by EMS was not monitored, and staff attention was diverted. Multiple staff members, including the DON, LVNs, and CNAs, stated they were not aware that the exit door alarm was not working. Additionally, it was observed that residents with high cognitive scores had access to the keypad code for the exit doors, and there was no list of which residents knew the codes. The facility's logbook for door checks was incomplete, and not all exit doors were being checked as required by policy. The resident was missing for several days, during which time she was exposed to cold weather and missed her medications, before being found by law enforcement on a bus and taken to the hospital. The facility failed to follow its own elopement prevention and response policies, which required all exit doors to have functioning alarms and to be checked each shift, as well as monitoring of doors during EMS entry and exit. The responsible party (guardian) was not notified immediately of the resident's elopement, and there was a delay in communication. The deficiency was identified as Immediate Jeopardy due to the failure to provide adequate supervision and maintain a safe environment, resulting in the resident's elopement and exposure to potential harm.
Removal Plan
- Resident #8 was readmitted to a room across from the nurse's station for better monitoring and placed on one-to-one supervision to assure safety and monitor for elopement tendencies.
- Implement a check procedure with nursing to document Resident #8's presence.
- Activities and meal attendance for Resident #8 will be completed with an escort.
- All exit doors were checked by Maintenance to confirm alarms were operational and documented.
- Any EMS arrival requires a dedicated staff member posted at the door to maintain supervision during the entire EMS presence in the building.
- A full resident headcount was completed by the DON to ensure no other residents were missing or unaccounted for.
- All on-duty staff were re-educated on elopement prevention policy, door-monitoring requirements during emergencies, and that exit codes will not be shared with residents or visitors.
- Random competency quizzes will be completed.
- Exit door audits will be completed.
- Review of elopement risk assessments for all residents, including Resident #8.
- Full staff retraining on elopement procedures, supervision, and emergency response for all active personnel, with PRN or leave staff retrained prior to return.
- Maintenance audit of all door alarms will be completed.
- Administrator/DON will audit 100% of EMS entry/exit logs, door monitoring logs, and elopement assessments.
- Mock elopement drills will be completed.
- All audits and drill results will be reviewed in Standards of Care meetings, with immediate corrective action for any deviations.
Failure to Immediately Notify Guardian After Resident Elopement
Penalty
Summary
The facility failed to immediately notify the resident's legal representative, a court-appointed guardian, after the resident eloped from the facility. The resident, an elderly female with severe cognitive impairment due to multiple strokes and other significant medical conditions, was discovered missing during evening rounds. Staff initiated a search, notified law enforcement, the administrator, the DON, and family members, but did not promptly contact the resident's guardian as required by facility policy and federal regulations. Record reviews and interviews revealed that the resident's guardianship had been established due to her cognitive deficits, and the guardian was listed as the responsible party. Despite this, there was confusion among staff regarding who was responsible for notifying the guardian, with some assuming that management would handle the notification. Documentation and interviews indicated that the guardian was not notified until several hours after the resident was found missing, with conflicting accounts of the exact timing of notification. The facility's policy required immediate notification of the legal representative within one hour of recognizing a significant change in the resident's condition, such as elopement. The delay in notifying the guardian was confirmed by both facility staff and the guardianship agency. The resident was eventually found several days later by a bus driver and transported to the hospital, where she was admitted for further assessment. The hospital case manager also noted that the guardian had not been notified in a timely manner about the elopement. The deficiency centers on the facility's failure to promptly inform the resident's legal representative of a significant event affecting the resident, as required by policy and regulation.
Missing Physician Order for CPAP Machine
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was using a continuous positive airway pressure (CPAP) machine. Record reviews showed that while the resident's care plan, progress notes, and hospital discharge summary all referenced the use of a CPAP machine at night, there was no corresponding physician order for this treatment in the monthly physician orders for the relevant period. The resident's face sheet and Minimum Data Set (MDS) assessments also documented the use of the CPAP machine, and direct observation confirmed the presence of the device at the bedside. Interviews with nursing staff confirmed the resident's use of the CPAP machine, but staff were unaware of why the physician order was missing from the records. The Director of Nursing (DON) acknowledged that the omission may have occurred during the resident's discharge and subsequent re-admission, resulting in the physician order not being reactivated. The facility's policy requires that all drug and biological orders be recorded on the physician's order sheet in the resident's chart, but this was not done for the CPAP machine. The deficiency was identified through observation, interview, and record review, which collectively demonstrated that the facility did not ensure the resident's medical record was complete and accurately documented regarding the use of the CPAP machine.
Failure to Notify Physician and Family After Resident Fall Resulting in Death
Penalty
Summary
The facility failed to immediately notify a resident's physician and family member following an unwitnessed fall that resulted in injury and ultimately the resident's death. The resident, a male with diagnoses including muscle weakness, unsteadiness on feet, cognitive communication deficit, and muscle wasting, was assessed as being at risk for falls and required assistance with mobility. After experiencing an unwitnessed fall, the resident was found with redness on the back of his head and neck, but there was no documented evidence that the physician or family were notified of the incident. Nursing staff involved in the incident did not recall or document notifying the physician or the resident's family member after the fall. The nurse who responded to the fall assessed the resident but did not inquire if the resident had hit his head, nor did she notify the physician or family. Subsequent staff were not informed of the fall, and the resident was later found unresponsive and subsequently passed away after being transported to the hospital. The family was only notified when the resident was being sent to the hospital, and observed injuries at that time. Interviews with facility leadership and staff confirmed that the facility's policy required immediate notification of the physician and family after such incidents, but this was not followed. Documentation related to neurological checks and notifications was incomplete or missing. The physician stated he was not notified of the fall and expected to be informed of such events due to the risk of head trauma. The failure to notify the appropriate parties was identified as an Immediate Jeopardy situation by surveyors.
Failure to Protect Resident from Neglect After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to protect a resident's right to be free from neglect following an unwitnessed fall with a head injury. The resident, who had a history of muscle weakness, unsteadiness, and required assistance for mobility, experienced an unwitnessed fall in the evening. The nurse on duty assessed the resident and noted redness on the back of the head/neck area but did not complete or document ongoing neurological checks as required by facility policy. Additionally, there was no documentation of family or physician notification regarding the fall, and the facility's fall protocol and the resident's person-centered care plan were not followed. The medical record review revealed that neurological monitoring was only initiated for a short period and was incomplete, with the remainder of required checks not performed or documented. The nurse did not complete an incident report, and the post-fall evaluation, including assessments for delayed complications and changes in the resident's condition, was not conducted. The resident was found unresponsive the following morning and subsequently passed away. Interviews with staff confirmed a lack of communication and understanding of the facility's fall protocol, as well as insufficient training and knowledge regarding required post-fall assessments and documentation procedures. Further interviews with facility leadership and staff indicated that the nurse responsible for the initial assessment lacked adequate training on the facility's electronic medical record system and was unaware of the full scope of required post-fall procedures. The failure to follow established protocols, conduct ongoing monitoring, and communicate with the physician and family constituted neglect, as defined by facility policy and federal regulations. The deficiency was identified as Immediate Jeopardy due to the systemic failures in assessment, documentation, and communication following the resident's fall.
Failure to Ensure Nursing Staff Competency in Post-Fall Assessment and Notification
Penalty
Summary
Nursing staff at the facility failed to demonstrate the necessary competencies and skills to provide safe and appropriate care for a resident who experienced an unwitnessed fall. The resident, who had a history of muscle weakness, unsteadiness, and mobility issues, was found to have fallen and sustained redness to the back of his head and neck. Despite these findings, there was no documented evidence that neurological checks were properly conducted, nor that the resident’s family or physician were notified of the incident. The nurse involved did not complete the required post-fall assessments or incident report, and only provided an oral report to the DON. The nurse also lacked knowledge of the facility’s fall protocol, procedures, and the use of the EMR system, having received only minimal training before being assigned as charge nurse. Further review revealed that the last documented fall risk or post-fall evaluation for the resident was not completed for the most recent fall, and there was no follow-up for delayed complications related to the incident. The neurological monitoring initiated was incomplete, and subsequent checks were not performed as required. Other staff, including the RN on the following shift, were not informed of the fall and therefore did not continue necessary monitoring. Interviews with facility leadership confirmed that the fall protocol was not followed, care plan interventions were not implemented, and required documentation was missing. The facility’s policies required immediate and ongoing assessment, documentation, and notification following a fall, none of which were adequately carried out in this case. The resident was later found unresponsive and subsequently passed away after being transported to the hospital. Interviews with family members indicated they were not notified of the fall until after the resident was sent to the hospital. The physician also confirmed he was not informed of the fall. Facility leadership acknowledged that the expected protocols and procedures were not followed, and that the nurse involved did not possess the necessary competencies to perform required assessments or documentation. The failure to ensure staff competency and adherence to protocols placed residents at risk for significant harm.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated for one resident who experienced an injury of unknown origin. Staff observed the resident with discoloration on the buttocks, which was later confirmed to be associated with an acute, mildly displaced comminuted right proximal femoral fracture. Despite the presence of a significant injury and the facility's policy requiring prompt and thorough investigation of injuries of unknown origin, there was no documentation or evidence that an investigation was initiated or completed to determine the cause of the injury. Multiple staff members, including CNAs, RNs, the ADON, and the DON, acknowledged that the injury was of unknown origin and recognized the importance of investigating such incidents. The DON stated that she was informed of the injury and instructed staff to notify the physician and obtain an x-ray, but did not initiate or conduct an investigation. The ADM, who was responsible for investigating injuries of unknown origin, reported not being notified of the incident until informed by surveyors and confirmed that no investigation had been conducted. The facility's own policy, revised in December 2024, required that all reports of resident abuse, neglect, and injuries of unknown source be promptly and thoroughly investigated by management. Despite this, interviews and record reviews confirmed that the required investigation did not occur, and there was no evidence to show that the facility attempted to determine how the resident sustained the injury.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision for a cognitively impaired resident with a high risk for falls. The resident, who had severe cognitive impairment, bilateral hip osteoarthritis, osteoporosis, schizoaffective disorder, vascular dementia, muscle weakness, lack of coordination, and right eye blindness, required substantial to maximal assistance with transfers and was care planned for two-person assistance. There was no documentation indicating the use of a mechanical lift for transfers, despite this being required. On the day prior to the resident's hospital transfer, staff observed the resident had pain and dark discoloration on the buttocks during repositioning for perineal care. The resident reported having fallen, but could not provide details. Staff did not complete a skin assessment as required, and there was no documentation of an accident or incident prior to the discovery of the injury. The resident was later found to have an acute, displaced femoral fracture and was sent to the hospital for surgery. Multiple staff interviews revealed inconsistent knowledge and practices regarding the resident's transfer status, with some staff relying on verbal reports or outdated lists rather than the care plan or electronic medical record (EMR). Further interviews indicated that staff, including CNAs and nurses, were not consistently following the facility's fall protocol when a cognitively impaired resident reported a fall or presented with a new skin issue. The facility's policies required notification of the physician and responsible party, completion of assessments, and documentation of incidents, but these steps were not followed. The resident's roommate reported that staff often used only one-person assistance for transfers, and there was uncertainty among staff about the proper use of mechanical lifts. There was also a lack of in-service training related to fall protocol, transfers, and accident/incident management during the relevant period.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made. Specifically, staff observed a resident with discoloration to the buttocks area, which was later confirmed as an acute femur fracture. Despite multiple staff members, including the ADON, DON, and CNA, recognizing the injury as one of unknown origin and acknowledging the requirement to report such incidents to the State Survey Agency (SSA), the injury was not reported as required. The resident involved had significant medical conditions, including bilateral primary osteoarthritis of the hip, age-related osteoporosis, schizoaffective disorder, vascular dementia, muscle weakness, lack of coordination, and severe cognitive impairment. The resident was at risk for falls and complications related to his diagnoses. Staff first noticed the discoloration and pain during routine care and subsequently ordered a stat x-ray, which revealed a right proximal femoral fracture. The resident was then transferred to the hospital for further evaluation and management. Throughout the process, staff interviews confirmed that the source of the injury was unknown and met the criteria for an injury of unknown origin. Despite facility policy and regulatory requirements mandating immediate reporting of such injuries, the DON, ADON, and other staff did not notify the SSA within the required timeframe. Interviews revealed that staff were aware of the importance of reporting injuries of unknown origin but failed to do so. The facility's in-service records also showed no recent training related to reporting injuries of unknown origin. The administrator stated she was not informed of the injury and only learned of it during the surveyor's interview.
Failure to Provide Safe and Appropriate Tracheostomy Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care, including tracheostomy care and suctioning, for residents who required such interventions. One resident, who was admitted with a tracheostomy and a history of acute respiratory failure, did not have physician orders in place for trach care or suctioning since admission. Nursing staff did not perform regular tracheostomy care, citing discomfort and lack of training, and instead allowed the resident to perform his own trach care without supervision or documented competency. The resident was observed reusing disposable cannulas and cleaning them in non-sterile conditions, and his responsible party reported having to bring supplies from home. The resident was later hospitalized and diagnosed with pneumonia after experiencing respiratory distress and low oxygen saturation. Another resident with a tracheostomy and severe cognitive impairment also did not receive trach care and suctioning according to professional standards. Observations revealed that a nurse performed trach care without following infection control protocols, such as proper hand hygiene, use of sterile equipment, and appropriate suctioning technique. The nurse also reported not receiving adequate training or periodic competency evaluations for trach care, and had difficulty locating necessary supplies. Multiple staff interviews confirmed gaps in training, lack of skill checks, and uncertainty about who was responsible for trach care education and oversight. Record reviews showed that the facility's policies required physician orders for trach care, adherence to sterile technique, and regular staff training and competency checks. However, these requirements were not met, as evidenced by the absence of orders, improper care practices, and lack of documentation of staff competencies. The failures were identified as placing residents at risk for infection, respiratory distress, and other complications, and resulted in the identification of an Immediate Jeopardy situation by surveyors.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to provide safe and appropriate pain management for a resident with chronic pain and multiple complex medical conditions, including acute respiratory failure, tracheostomy status, dysphagia, chronic pain, and end-stage renal disease. The resident had a physician's order for Hydrocodone-Acetaminophen to be administered as needed for pain, but the medication was not reordered in a timely manner, resulting in the resident running out of the medication and experiencing excruciating pain for two days. During this period, the resident repeatedly requested pain relief and ultimately requested to be sent to the emergency room due to unrelieved pain. The resident's responsible party reported that the resident was crying and in severe distress due to lack of effective pain control. Documentation failures were also identified, as the resident's medication administration record (MAR) did not match the narcotic count sheet for PRN Hydrocodone, raising concerns about accurate medication administration and record-keeping. Additionally, the facility did not consistently assess or document the effectiveness of PRN Hydrocodone after administration, as required by physician orders and facility policy. Interviews with nursing staff revealed that documentation was sometimes missed due to being busy, and that pain assessments following PRN administration were not consistently performed or recorded. The nurse practitioner and director of nursing both stated that they were not notified in a timely manner about the resident's medication running low, and that the order for PRN Hydrocodone was not appropriate for the resident's needs in the facility setting. The facility's policies required timely reordering of medications, accurate documentation, and follow-up assessment of pain management interventions, but these were not followed. These failures led to the identification of Immediate Jeopardy by surveyors, as the resident was left without effective pain management and required transfer to the hospital for pain control.
Failure to Ensure Competent Tracheostomy Care by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skills to provide safe and effective care for a resident with a tracheostomy. Direct observation revealed that a nurse performed tracheostomy care and suctioning without adhering to professional standards of practice, including failure to perform hand hygiene, improper use of gloves, use of non-sterile equipment, and not following required procedures for oxygenation and suctioning. The nurse did not clean the resident’s trach stoma or change saturated dressings, and did not check or adjust oxygen prior to or during the procedure. The resident was observed with excessive secretions, soiled dressings, and was visibly distressed during the care. Interviews with multiple nursing staff indicated a lack of adequate training and competency validation in tracheostomy care. Several nurses reported not receiving hands-on training, periodic evaluations, or instruction on the use of trach care equipment. One nurse stated she had only practiced on mannequins and would require supervision to perform the procedure on a resident. Another nurse reported not being familiar with the resident or the necessary equipment, and both nurses expressed the need for reeducation on trach care. The responsible director of nursing was unable to provide documentation of staff competency evaluations when requested. The facility’s own policies required sterile technique, hand hygiene, and specific steps for tracheostomy care and suctioning, which were not followed during the observed incident. The lack of staff training, competency checks, and adherence to policy resulted in an Immediate Jeopardy situation, as staff were not equipped to safely care for residents with tracheostomies. The deficiency was identified through direct observation, staff interviews, and review of facility records and policies.
Removal Plan
- The facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies will be safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.
- Residents #2 and #3 were identified as potentially affected and will be discharged accordingly. They have been assessed by Consultant RN and found to be safe, unaffected by deficiencies and in no distress. They will be discharged upon formulation of discharge plan. Resident #2 will be discharged to SNF and Resident #3 will be discharged to hospital pending SNF placement due to need for dialysis.
- A Special Bulletin inservice with sign-in sheet. RN consultant to review. The Facility does not maintain a policy for residents to provide their own treatments outside of self-administration of medication; if a resident refuses or is non-compliant with ordered nursing procedures or treatments it will be documented in progress notes, physician notified, and care plan will be updated. All clinical staff and admissions team members have been notified by mass message that we will no longer accept residents or referrals for tracheostomy dependent residents.
- The facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies have been safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.
- IJ and POR reviewed during adhoc QAPI with medical director, administrator, outside consultant and DON; POR and POC will be reviewed during monthly QAPI and revised as needed, to sustain improvement. An adhoc QAPI was conducted via teleconference to update education plan and review of revisions. An adhoc QAPI was conducted including RT to discuss further areas of revision to POR and engagement of RT, duties and oversight responsibilities. A QAPI will be held to notify and discuss plan and new clinical capabilities with medical director.
Failure to Provide Required Written Discharge Notices and Appeal Rights
Penalty
Summary
The facility failed to provide written notification to two residents and their representatives regarding facility-initiated discharges, including the reasons for the move, the right to appeal, and the required contact information for the State Long-Term Care Ombudsman. In both cases, the residents and their families were not given written notice in a language and manner they understood, nor was the notice provided at least 30 days in advance as required. Additionally, the facility did not send a copy of the discharge notice to the Ombudsman for either resident. One resident, a male with a history of tracheostomy, cerebral infarction, and respiratory failure, was discharged to another skilled nursing facility. The resident's family reported receiving only a phone call from the social worker on the day of discharge, with no written notice or options for alternative placements. The family was not informed of the actual discharge date or the final destination, and there was confusion regarding which facility the resident was transferred to. Documentation in the electronic medical record did not include a discharge notice, and the family learned of the discharge after it had already occurred. Another resident, a female with hemiplegia, hemiparesis, cognitive communication deficit, and acute respiratory failure, was sent to an acute care hospital and subsequently not allowed to return to the facility. The family was informed by phone that the resident would not be readmitted due to staffing limitations, but did not receive written notice, information about the discharge location, or the resident's appeal rights. The facility's own policies required consultation with the resident or representative, provision of discharge details, and notification of the Ombudsman, none of which were followed in these cases.
Failure to Administer and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for two residents who were being treated for pressure ulcers. For both individuals, physician orders for wound care were not followed on multiple consecutive days, as documented in the Treatment Administration Records (TARs). Specifically, wound care treatments ordered by the physician were not administered on four separate days for each resident, and these omissions were not documented or explained in the medical records. One resident, a male with diagnoses including acute congestive heart failure, obesity, asthma, and edema, was assessed as being at risk for pressure ulcers and had specific wound care orders in place. Despite these orders, the TARs showed that the prescribed wound care was not provided on several days. Similarly, a female resident with chronic obstructive pulmonary disease, muscle weakness, end-stage renal disease, hypertension, and a pressure ulcer also did not receive the ordered wound care on the same dates. Observations confirmed that, at the time of survey, there was no infection or worsening of wounds, but the required treatments had not been administered as ordered. Interviews with facility staff revealed confusion and lack of communication regarding responsibility for wound care, particularly in the absence of the wound nurse (WN). Nurses on duty sometimes assumed the WN would provide the care, resulting in missed treatments. The Assistant Director of Nursing (ADON) and other staff acknowledged the importance of adhering to physician orders and confirmed that the omissions occurred. Facility policies required documentation of all wound care provided, but the records did not reflect that the treatments were given as ordered.
Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a nurse failed to adhere to infection prevention and control protocols during tracheostomy care and suctioning for a resident with significant medical needs. The nurse did not perform hand hygiene before and after glove changes, and did not follow sterile technique while suctioning. Specifically, the nurse donned gloves without hand hygiene, used soiled gloves to access personal items, and repeatedly failed to sanitize hands between glove changes. The nurse also used non-sterile equipment and did not properly clean or change necessary items during the procedure. The resident involved was a male with a history of tracheostomy, acute and chronic respiratory failure with hypoxia, gastrostomy, congestive heart failure, cerebral infarction, and dysphagia. He required ongoing oxygen therapy, suctioning, and tracheostomy care, and was assessed as having severe cognitive impairment. Physician orders and care plans specified the need for regular trach care, suctioning, and monitoring for signs of infection, with clear instructions for maintaining sterility and hand hygiene. Facility policies reviewed by surveyors outlined the requirement for hand hygiene before and after resident contact, between glove changes, and after removing gloves, as well as the use of sterile technique for invasive procedures. During interviews, the nurse acknowledged awareness of hand hygiene protocols but cited lack of sanitizer in the room as a reason for non-compliance. The Director of Nursing confirmed expectations for staff to follow infection control policies, including proper hand hygiene and sterile technique during trach care.
Failure to Ensure a Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Obtain and Document Orders for Colostomy and Dialysis Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive care plan, and residents' preferences for three residents. One resident with a history of spina bifida, epilepsy, muscle weakness, and paraplegia was admitted with a colostomy, but there were no physician orders in place for managing or maintaining the colostomy since admission. The resident's care plan addressed bowel incontinence and skin integrity but did not include specific interventions for colostomy care, and the physician orders lacked any direction for colostomy management. Additionally, two residents with chronic kidney disease and other comorbidities required regular dialysis treatments. Although their care plans and assessments indicated the need for dialysis, there were no physician orders specifying the days on which dialysis was to be provided, despite both residents attending dialysis sessions on a set schedule. Interviews with facility staff, including the DON, RN, and ADON, confirmed that orders for colostomy care and dialysis schedules were expected but missing, and that the absence of such orders could result in missed care.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for several residents requiring Enhanced Barrier Precautions (EBP). Surveyors observed that signage indicating the need for personal protective equipment (PPE) was missing from the doors of four residents who had conditions such as open wounds, indwelling catheters, and pressure ulcers. Additionally, PPE bins were not present at these residents' doors, and staff were not consistently informed or aware of which residents required EBP. Staff interviews revealed a lack of understanding regarding EBP, with some CNAs stating they had never been instructed to wear gowns for high-contact care or catheter care for these residents. Direct observations showed that staff, including the ADON, did not wear appropriate PPE such as gowns while performing high-contact care activities like wound care, dressing, and bathing for residents with open wounds or indwelling catheters. In one instance, the ADON performed wound care on a resident's left heel without changing gloves or performing hand hygiene after removing a soiled dressing, thereby contaminating the wound. The ADON also did not wear a gown during this procedure, and similar lapses were observed during care for other residents requiring EBP. Review of the facility's policies indicated that PPE should be used as needed during wound care, and that infection control policies were intended to prevent and manage transmission of diseases. However, the facility was unable to provide current hand hygiene and EBP policies when requested. Interviews with staff and management confirmed that there had been no recent in-service training on EBP, and that responsibilities for ensuring PPE availability and signage were unclear or not consistently followed. These failures were observed for residents with significant medical needs, including chronic wounds, indwelling catheters, and other conditions requiring strict infection control measures.
Delayed Catheter Reinsertion and Inadequate Bladder Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to promptly reinsert a foley catheter for a female resident with multiple sclerosis, neuromuscular dysfunction of the bladder, paralytic syndrome, and overactive bladder. The resident's care plan and physician orders indicated the need for an indwelling catheter due to neurogenic bladder, with instructions to maintain and change the catheter as needed. On the morning in question, the resident's catheter was found to have come out, and the certified nursing assistant (CNA) notified the RN. Despite the resident expressing discomfort and a preference for the catheter to be reinserted, the RN delayed replacement for over eight hours, only reinserting the catheter in the afternoon after being prompted by the Director of Nursing (DON). Throughout the day, the resident was unable to sense when she was voiding, which caused her distress. Interviews with staff confirmed that the RN was aware of the situation but chose to postpone the procedure, and the nurse practitioner (NP) stated that such a delay could lead to urinary retention and a distended bladder. The facility was unable to provide a catheter care policy when requested. The failure to provide timely catheter care and adhere to physician orders constituted a deficiency in ensuring appropriate treatment and services to prevent urinary tract infections for the resident.
Failure to Notify Physician and Responsible Party of Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a resident's physician and responsible party of a significant change in the resident's condition. The resident, an older male with a history of stroke, dementia, chronic pain, and nicotine dependence, experienced a notable decline over several days. Staff observed that he was no longer getting out of bed, was unable to feed himself, and complained of leg pain during personal care. Despite these changes, there was no timely documentation or notification to the nurse practitioner or responsible party regarding his altered status. Multiple staff interviews revealed that the resident's decline was apparent for several days, with increased lethargy, decreased participation in meals, and a cessation of his usual smoking routine. Some staff members noted the changes but did not consistently communicate them to the nursing team or document them in the medical record. The resident's responsible party was not informed of these changes and only became aware of the situation after visiting and finding the resident unresponsive and in bed, which was a significant deviation from his baseline behavior. The lack of prompt notification and documentation led to a delay in medical intervention. The resident was eventually transferred to the hospital, where he was diagnosed with possible aspiration pneumonia, a urinary tract infection, and a left femur fracture. The facility's policy required immediate notification of significant changes in a resident's condition to the physician and responsible party, but this protocol was not followed in this case, resulting in the identification of an Immediate Jeopardy situation.
Failure to Recognize and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences for one resident reviewed for quality of care. The resident, an older male with a history of stroke, dementia, chronic pain, and nicotine dependence, experienced a significant change in condition that was not promptly recognized, addressed, or documented by staff. Over several days, the resident became increasingly lethargic, stopped getting out of bed, was unable to feed himself, and complained of leg pain during personal care. Despite these changes, there was no timely follow-up or documentation regarding his post-fall status, pain, lethargy, or decreased functional abilities. Multiple staff interviews revealed that the resident's decline was observed by CNAs and nurses, including his staying in bed, not eating independently, and not smoking as usual. Some staff noted the changes but did not consistently notify the nurse or document the observations. Nurses who were aware of the changes did not escalate the concerns or notify the nurse practitioner (NP) or physician in a timely manner. The resident's responsible party was also not informed of the changes until after a care plan meeting, at which point the resident was found to be difficult to arouse and not at his baseline. The resident was eventually assessed as febrile, hypertensive, and unresponsive, leading to his transfer to the hospital, where he was diagnosed with possible aspiration pneumonia, a urinary tract infection, and a left femur fracture. The facility's policy required prompt notification of significant changes in a resident's condition to the physician and responsible party, but this protocol was not followed. The failure to recognize and act upon the resident's change in condition resulted in the identification of Immediate Jeopardy by surveyors.
Failure to Maintain Safe and Comfortable Temperatures for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for seven residents by not keeping temperatures within the required range of 71 to 81 degrees Fahrenheit on two halls. Multiple residents reported that the air conditioning had not been working for at least two weeks, with some stating it had been out for up to three months. Observations confirmed that room and hallway temperatures repeatedly exceeded 81 degrees, with thermostat readings as high as 83 degrees. Several residents were provided with window air conditioning units or fans, but not all rooms had these, and some residents continued to experience discomfort due to heat. Maintenance logs and staff interviews indicated that complaints about room temperatures and requests for fans or air conditioning units had been made over several weeks, but not all were addressed promptly. Residents affected by the heat had various medical conditions, including chronic obstructive pulmonary disease (COPD), diabetes mellitus, heart failure, vascular dementia, and other serious health issues. Some care plans specifically included interventions to avoid exposure to extreme heat or cold, and to encourage adequate hydration. Despite these documented needs, residents reported feeling excessively hot, sweating, and in some cases, needing to move to cooler areas of the facility. Observations showed that not all residents had access to fans or functioning air conditioning, and some staff acknowledged that complaints had been made but not always acted upon. Interviews with facility staff and maintenance personnel revealed a lack of consistent monitoring and documentation of room temperatures, especially during periods when the central air conditioning was not functioning. The maintenance supervisor and administrator provided conflicting accounts regarding the duration and extent of the air conditioning failure. Maintenance logs showed delayed responses to requests for cooling equipment, and the facility's emergency preparedness plan, which included procedures for heat alerts and relocating residents, was not fully implemented. The air conditioning repair company confirmed that repairs could have been completed sooner if requested, but delays in obtaining quotes and authorizations contributed to the prolonged period of inadequate temperature control.
Failure to Provide Timely Behavioral Health Services and Protect Residents from Harm
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of bipolar disorder and a history of aggressive behaviors received timely and necessary behavioral health care and services. Despite physician orders for psychiatric evaluation and management issued on two separate occasions, there was a significant delay in the resident being seen by psychiatric services. The resident exhibited escalating behaviors, including yelling, threatening, and physical aggression towards staff and other residents, which were documented in progress notes. The care plan included interventions for managing mood and behaviors, but these were not effectively implemented, and the resident did not receive psychological therapy as indicated in the MDS assessment. The resident's aggressive behaviors culminated in an incident where she scratched another resident with her fingernails during an outburst, resulting in injuries to the other resident's thigh. Documentation showed that the resident had a pattern of verbal and physical aggression, including threats with utensils and physical altercations. Staff interviews confirmed that the resident had ongoing behavioral issues since admission, and there was a lack of timely psychiatric intervention despite multiple referrals and physician orders. The delay was attributed to issues with the psychiatric service provider, including staff turnover and insurance problems, but there was no evidence of follow-up or alternative arrangements to ensure the resident's behavioral health needs were met. The other resident involved in the altercation had moderate cognitive impairment and required substantial assistance with activities of daily living. He sustained injuries as a result of the incident and expressed dissatisfaction with his care following the altercation. The facility's failure to implement behavioral health interventions and protect residents from harm was further evidenced by the lack of documentation of behavioral monitoring and the absence of timely psychiatric evaluation, despite clear indications and orders for such services.
Removal Plan
- Resident #1 was assessed and noted to be stable.
- An audit of Resident #1's current list of medications was performed by the Administrator to ensure all current medications were delivered and available in the facility.
- Resident #1 will be seen by Psych services for follow up and intervention (personal safety).
- Resident #1's care plan was updated with current psych diagnosis and interventions as well as specific behaviors and interventions.
- One on one monitoring has been placed for Resident #1 when near other residents until stable per psych NP recommendation or transfer out of the facility.
- Resident #2 was assessed after the event involving Resident #1, revealing no signs of distress or emotional agitation.
- Training of staff and audits of all residents identified as in need of behavioral health services as well as abuse and neglect were initiated by the Administrator.
- A spreadsheet was created with the identification of the services and if services were needed.
- The facility is verifying comprehension on staff training by following up after education based on a random selection.
- Staff will not be allowed to work their shifts until this Inservice and training has been completed.
- The Administrator will be responsible for the direct Inservice of her staff.
- All residents who have diagnoses or demonstrated signs of behavioral health concerns have the potential to be impacted by this deficient practice.
- The Administrator is directing the review of all residents with Behavioral Health diagnoses to identify unmet behavioral or psychiatric needs.
- All open psychiatric referrals were verified and re-submitted or scheduled.
- Review of all residents with Behavioral Health Diagnosis was started and completed by DON, ADON, Administrator.
- Creation of spreadsheet identifying unmet behavioral or psychiatric needs. Any other residents identified will be referred to psych as well. Responsible: DON, Admin, Social Worker.
- A review of their medications will be completed as well. The Psychiatrist will assist with any referrals or review of concerns that were identified with this audit.
- A review is scheduled for the Psychiatrist and Attending Physician on the medications as it relates to any current behaviors or events since the last Dose Reduction Review.
- The Regional Director of Operations has educated the Administrator, DON and ADON on behavioral care and services for the residents for the facility and comprehension will be verified at this same time.
- The administrator has created an audit tool to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders on behavioral health matters.
- Audits will be conducted by the DON daily for two weeks, weekly for two weeks and monthly for two months.
- A spreadsheet was created for the audit to be conducted and documented.
- Any negative findings will be reported to the administrator for immediate correction.
- The Medical Director was notified of the deficiency (F740) and an Ad-Hoc QAPI meeting was held to discuss the findings.
- All findings will be reported to the QAPI team for QAPI.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, or misappropriation were reported immediately to the State Survey Agency, as required. Specifically, an incident occurred in which one resident grabbed another resident's walker and pushed it, causing the second resident to fall and sustain a large skin tear on his forearm. This event was documented in progress notes and reported internally to the Director of Nursing (DON) and Nurse Practitioner (NP), but was not reported to the State Survey Agency within the required timeframe. Resident records show that the injured resident had a history of thrombocytopenia, muscle weakness, recurrent falls, chronic kidney disease, and alcoholic cirrhosis, and required a walker for mobility. The resident's care plan included interventions to prevent falls, and wound care orders were in place following the incident. The resident who caused the fall had diagnoses including encephalopathy, cognitive communication deficit, Alzheimer's disease, and unspecified dementia, with documented behavioral issues and a care plan addressing potential for verbal and physical aggression. Interviews with staff revealed that the incident was reported internally but not externally, as the administrator did not believe the event constituted abuse due to a perceived lack of malicious intent. Facility policy required immediate reporting of all suspected or substantiated incidents of abuse, including resident-to-resident abuse, to the appropriate state agencies, but this protocol was not followed in this case.
Failure to Notify Physician of Missed Medications Due to Resident Absence
Penalty
Summary
The facility failed to immediately notify a resident's physician or nurse practitioner when multiple doses of prescribed medications were missed due to the resident being out on pass. The resident, who had diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, was noted to have missed several doses of critical medications such as aspirin, divalproex, doxepin, haloperidol, folic acid, multivitamin, and metoprolol over several days when she was away from the facility. Medication Administration Records (MAR) indicated these missed doses, but there was no documentation that the physician or nurse practitioner was notified upon the resident's return. Interviews with nursing staff revealed inconsistent practices regarding notification of missed medications. Some staff stated that they would notify the nurse practitioner or physician depending on the number of missed doses, while others indicated that the expectation was to always notify and document such events in the progress notes. However, review of the resident's progress notes confirmed that no such notifications or documentation occurred for the missed medications during the relevant period. The nurse practitioner also confirmed that he was not informed about the missed doses and emphasized the importance of being notified to provide appropriate recommendations. Further review showed that the facility's policy required prompt notification of the physician for changes in a resident's condition or status, including refusal or missed medications. Despite this, there was no evidence of staff training on this requirement during the period in question, and staff interviews indicated a lack of clarity and consistency in following the policy. The deficiency was identified through record review and staff interviews, which confirmed the failure to notify the physician or nurse practitioner as required.
Failure to Ensure Proper Administration and Notification for Missed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for a resident. The resident, a woman with multiple diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, had physician orders for several medications including aspirin, doxepin, divalproex, haloperidol, folic acid, multivitamin, and metoprolol. Review of the medication administration record (MAR) showed that multiple doses of these medications were missed on several days, with the MAR indicating the resident was 'away from the facility' during those times. The resident frequently went out on pass, sometimes overnight, and staff interviews revealed that when a resident was out during medication times, the MAR was marked accordingly. However, there was inconsistency in notifying the nurse practitioner (NP) or physician about missed medications, and documentation of such notifications was lacking. Staff interviews indicated that while some nurses believed they should notify the NP or physician and document it in the progress notes, this was not consistently done. The NP confirmed that he was not informed about the resident missing several days of medications and emphasized the importance of such notifications for clinical decision-making. Facility policy required prompt notification of the physician for changes in a resident's condition or status, including refusal or missed medications, and documentation of such notifications. Despite this, the review found no evidence that the NP or MD was contacted when the resident returned after missing medications, nor was there documentation in the progress notes. The failure to follow established procedures for medication administration and notification led to the deficiency.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to promptly assist residents in obtaining routine dental services, resulting in unmet dental needs for three residents. For one resident, physician orders indicated a referral to the dentist for a dental exam due to complaints of tooth and gum pain, but there was no documentation of a dental exam or follow-up in the progress notes, and the resident reported not having seen a dentist in over five years despite ongoing dental issues. Another resident had a physician order for denture placement and expressed a desire for new dentures, but there was no evidence that the referral was made within three days or that the resident was seen by a dentist, even though the resident reported discomfort from a broken tooth and requested denture adjustment. A third resident expressed the need for a dental cleaning and had not seen a dentist in over a year, despite a care plan indicating poor dental condition and a request for dentures. There was no documentation of a dental referral or appointment for this resident, and the last recorded dental visit was over a year prior, during which a new cavity was noted. Interviews with staff revealed confusion regarding responsibility for making dental referrals, with some believing it was the nurse's responsibility and others indicating it was the social worker's role. The social worker, who had started six months prior, was unclear about the previous dental provider and had only recently secured a new dental contract, but as of the time of the survey, no dental visits had occurred under the new arrangement. Facility leadership, including the DON and administrator, confirmed that social services was responsible for dental appointments and acknowledged delays in securing a dental contract and arranging dental visits. The facility's policy required routine and emergency dental services to be available in accordance with residents' assessments and care plans, with social services responsible for assisting with appointments. However, the lack of timely referrals and absence of dental services for the residents reviewed demonstrated a failure to meet these requirements.
Failure to Update Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by policy and regulatory standards. Specifically, the care plan did not reflect the resident's history of falls, despite documented incidents on three separate occasions. The resident, an older woman with multiple diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, was noted to have no cognitive impairment and was independent with transfers. However, her care plan did not include any mention of falls, even though incident reports documented both witnessed and unwitnessed falls without injury. Interviews with facility staff, including LVNs, the MDS RN, the DON, and the ADM, confirmed that falls should have been included in the resident's care plan and that it is the responsibility of various staff members to update the care plan with such information. The facility's policy requires that care plans be individualized, comprehensive, and revised as the resident's condition changes, incorporating measurable objectives and timetables. Despite these requirements and the staff's understanding of the process, the care plan was not updated to reflect the resident's falls, resulting in a deficiency.
Failure to Maintain Safe Wheelchair Conditions for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as evidenced by the inadequate maintenance of their wheelchairs. Resident #1, a male with a history of osteomyelitis and an above-the-knee amputation, reported that his wheelchair, which was from the 1960s, could not lock properly. Despite informing the social worker and therapy staff about the issue, no maintenance work order was recorded for his wheelchair. Interviews with the physical therapy assistant and occupational therapist confirmed that the wheelchair had a loose lock and was not safe for Resident #1, who was an amputee and required a stable wheelchair for safe transfers. Resident #2, a male with cerebral infarction, visual impairments, and a history of falls, also experienced issues with his wheelchair brakes. Although a work order was documented in the maintenance logbook, it was mistakenly marked as completed without the necessary repairs being made. During an observation, Resident #2 demonstrated that his wheelchair's left wheel did not lock, posing a risk of falling when he attempted to stand. The maintenance director acknowledged the error and expressed concern for Resident #2's safety, emphasizing that wheelchair repairs should be prioritized as emergencies. The facility's policies on maintenance and resident rights were not adhered to, as evidenced by the failure to address the residents' grievances and ensure their safety. The maintenance department's oversight in marking incomplete work orders as done and the lack of timely repairs for critical equipment like wheelchairs contributed to an unsafe environment for the residents. Interviews with staff, including the maintenance director and CNA, highlighted the communication breakdown and procedural lapses that led to the deficiencies.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by two specific incidents involving two residents. In the first incident, a certified nursing assistant (CNA) was observed using his phone during peri care for a female resident with a history of dysphagia, cerebral infarction, vascular dementia, and muscle weakness. The resident's family member provided video footage showing the CNA on his phone while the resident's lower body was exposed, which lasted for two minutes before the CNA resumed care. This incident was reported to the Director of Nursing (DON), who confirmed the CNA was texting during the care process. In the second incident, a male resident with paraplegia and a suprapubic catheter was observed moving through the facility without a privacy bag covering his catheter bag. Although the resident stated he was not bothered by the lack of a privacy bag, the facility's policy requires catheter bags to be covered to prevent potential embarrassment. The lack of a privacy bag was noted by a Licensed Vocational Nurse (LVN) only after it was pointed out, indicating a lapse in adherence to the facility's resident rights policy, which mandates treating all residents with kindness, respect, and dignity.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition through a gastrostomy tube had her head of bed (HOB) elevated at least 30 degrees, as required to prevent complications such as aspiration. On the evening of February 17, 2025, a licensed vocational nurse (LVN) connected the resident's feeding tube but did not elevate the HOB, leaving the resident lying flat. This oversight was captured on video footage provided by the resident's family member, who later found the resident struggling to breathe with foam around her mouth. The resident, a female with a history of dysphagia, cerebral infarction, vascular dementia, and muscle weakness, was on a continuous feeding regimen of Nepro at 50 ml/hr for 22 hours a day. Her care plan specified the need for HOB elevation during and after feeding. Despite this, the LVN left the resident's room without adjusting the bed, and the family member had to intervene by elevating the bed and clearing the foam from the resident's mouth, which alleviated her breathing difficulties. Interviews with facility staff, including the Director of Nursing (DON) and the LVN involved, revealed a lack of awareness and communication regarding the incident. The DON acknowledged the risk of aspiration if the HOB is not elevated and stated that all staff are responsible for ensuring proper positioning during tube feeding. The facility's policy and external guidelines both emphasize the importance of maintaining HOB elevation to prevent aspiration, yet this protocol was not followed, leading to the resident's distressing experience.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan for four residents within 48 hours of their admission, as required. This deficiency was identified through interviews and record reviews, which revealed that Residents #3, #4, #5, and #6 did not have baseline care plans completed. These residents had various medical conditions, including respiratory failure, end-stage renal disease, diabetes, pressure ulcers, cognitive communication deficits, and more. The absence of baseline care plans could lead to a lack of continuity of care and miscommunication among staff, potentially affecting the residents' immediate care needs. Interviews with facility staff, including the social worker, Director of Nursing (DON), and Administrator, highlighted that the facility was behind on care plans due to recent changes in management and staffing shortages. The social worker, who had been at the facility for only three weeks, acknowledged the backlog of care plans and the importance of having them completed to ensure proper resident care. The DON and Administrator also confirmed the delay in care plan completion and the potential for miscommunication among staff without them. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not adhered to for the residents in question.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which is a requirement to meet their medical, nursing, and psychosocial needs. The residents involved were admitted with various medical conditions, including respiratory failure, end-stage renal disease, diabetes, and cognitive communication deficits. Despite being cognitively intact, as indicated by their BIMS scores, these residents did not have completed care plans, which are essential for ensuring their needs and preferences are met. Interviews with facility staff, including the social worker, Director of Nursing (DON), and Administrator, revealed that the facility was behind on care plans due to recent changes in management and staffing shortages. The social worker, who had been at the facility for only three weeks, acknowledged the backlog of care plans and the potential for staff confusion in providing proper care without them. The DON and Administrator confirmed the facility's policy of completing a baseline care plan within 48 hours and a comprehensive care plan within seven days, but admitted that these were not being met, leading to potential miscommunication and inadequate care for the residents.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident during personal care. Specifically, a Certified Nursing Assistant (CNA) was observed changing a resident without closing the door or pulling the privacy curtain, leaving the resident exposed. The resident, a cognitively intact female with multiple health conditions including dementia and epilepsy, required substantial assistance with activities of daily living. Despite the CNA's training on resident rights, the privacy measures were not adequately implemented during the care process. Interviews with the CNA, Director of Nursing (DON), and Administrator (ADM) confirmed that staff were trained to ensure privacy during personal care activities. The DON and ADM acknowledged that failing to provide privacy could impact the resident's dignity. The CNA believed she had closed the door, but it did not remain shut, leading to the exposure. The facility's policy on dignity and privacy, dated August 2009, mandates the protection of resident privacy during personal care, which was not adhered to in this instance.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. The resident, a cognitively intact female with multiple diagnoses including respiratory failure, muscle weakness, and post-polio syndrome, was observed lying in bed with sheets soiled by a brown substance, later identified as spilled coffee. Despite the resident's dependency on staff for bed mobility and the presence of soiled sheets, the staff did not change the bedding promptly. Interviews with the CNA and DON revealed that the facility's policy required changing soiled bedding immediately to prevent skin breakdown and discomfort. However, the CNA did not change the sheets because the resident was not ready to get up, and the DON acknowledged that the sheets should have been changed. The ADM also confirmed that bedding should be changed as needed and expressed that the situation should have been handled by the nursing staff. The facility's failure to change the soiled sheets could have led to potential risks for the resident, such as skin breakdown and discomfort.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure a resident maintained acceptable parameters of nutritional status, resulting in a significant weight loss of 25.38% over six months. The resident, a male with diabetes, reduced mobility, muscle weakness, and feeding difficulties, experienced a decline in weight from 226.5 pounds to 169.0 pounds between May and November 2024. Despite the resident's quarterly MDS assessment indicating no weight loss and a care plan that did not address potential weight loss, the resident's weight records showed a clear decline. The resident's nutrition assessments by the RD were inconsistent with the recorded weights, and there was a lack of timely intervention to address the weight loss. Interviews with facility staff revealed a breakdown in communication and monitoring processes. The RD, who worked remotely, relied on information from the DM and did not independently verify weight loss data. The DM acknowledged the resident's deterioration and the late implementation of a supplement order in October. The NP and CNO expressed concerns about the lack of timely interventions and communication regarding the resident's weight loss. The facility's policy required monitoring and reporting of significant weight changes, but these procedures were not effectively followed, leading to the resident's unplanned weight loss.
Failure to Provide Timely Wound Care and Skin Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and the resident's care plan for a resident with a skin tear. The resident, a 47-year-old male with a history of cerebral infarction, type II diabetes, and muscle wasting, developed a skin tear on his left lower extremity. The facility did not conduct a complete skin assessment when the skin tear was first noted, and several wound care treatments were missed, leading to an infection that required antibiotic treatment. The resident's care plan included interventions for diabetes management, such as checking the body for skin breaks and treating them promptly. However, the facility did not adhere to this plan, as evidenced by missed treatments on specific dates. The resident's wound care orders were not consistently followed, and the necessary skin assessments were not conducted weekly as required by the facility's policy. Interviews with staff revealed a lack of communication and documentation regarding the resident's wound care needs. The facility's failure to perform timely skin assessments and adhere to wound care protocols resulted in the resident developing an infection. The resident's nurse practitioner was not informed of the wound until it had already worsened, and antibiotics were only started after the infection was identified. The facility's policies on skin assessments and wound care were not followed, contributing to the resident's compromised skin integrity and subsequent infection.
Failure to Provide Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident and their representative before discharging the resident. The resident, who had a BIMS score indicating cognitive intactness, was admitted with diagnoses including respiratory failure, type 2 diabetes, and hypertension. The resident left the facility without oxygen and refused to sign an Against Medical Advice (AMA) form. Despite this, the facility discharged the resident without providing the required notice or involving the Ombudsman. Interviews with facility staff revealed a lack of clarity and adherence to discharge procedures. The social worker acknowledged the necessity of a discharge notice and admitted that the resident should have been allowed to return since they did not sign an AMA. The RN confirmed that the resident was told they no longer lived at the facility and was not provided with discharge papers, leading to the resident's distress. The Chief Nursing Officer (CNO) and Administrator also confirmed that the resident was not given a discharge notice, and the facility's usual practice of documenting AMA refusals was not followed. The Nurse Practitioner (NP) was informed of the resident's desire to leave but did not approve a pass due to the resident's medical needs. The NP was not informed of the resident's return or subsequent discharge. The facility's discharge guidelines require notifying the resident in writing of the discharge and its reasons, which was not done in this case, leading to a deficiency in the facility's compliance with discharge procedures.
Inadequate Discharge Planning and Documentation
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident's discharge, which compromised the safety and orderliness of the transfer. The resident, an elderly female with multiple medical conditions including metabolic encephalopathy, sequelae of cerebral infarction, chronic pulmonary embolism, congestive heart failure, type 2 diabetes, and age-related physical debility, was discharged without a documented discharge plan. The resident had a moderate cognitive impairment and required substantial assistance with toileting hygiene, as indicated by her MDS assessment. The discharge process was inadequately managed, as evidenced by the lack of documentation regarding the resident's preparation for discharge. The facility's discharge policy, which mandates a post-discharge plan to be reviewed with the resident or their family at least 24 hours before discharge, was not followed. The resident was discharged to her family member's home without the family member being present, and there was no documentation of communication with the family or the resident about the discharge plans, including the involvement of home health services. Interviews with facility staff, including the Administrator and Social Worker, revealed a lack of awareness and adherence to the facility's discharge policy. The Administrator acknowledged the absence of documentation and communication, which could lead to delayed care or unsafe discharge. The Social Worker admitted to not having seen the discharge policy and failing to document the discharge process. The facility's failure to document and follow its discharge policy placed the resident at risk of not receiving necessary care and services upon discharge.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its written policies and procedures regarding prohibiting and preventing abuse for one resident reviewed for abuse and neglect policies. The facility did not report an allegation of rape made by a resident to the State of Texas and the facility administrator. The facility also failed to immediately notify the police of the alleged allegations and take action to protect the resident from possible physical and emotional abuse. This failure resulted in the identification of an Immediate Jeopardy (IJ) situation. The resident involved was a male with a history of paraplegia, traumatic brain injury, and several mental health conditions, including delusional disorder and bipolar disorder. Despite having a history of making false allegations, the resident's claims of being raped were not thoroughly investigated or reported as required by the facility's policies. The facility's administrator did not follow the protocol to report the allegations to the appropriate authorities or take measures to ensure the resident's safety. The administrator failed to document the incident in the resident's progress notes, inform the police, or discuss the possibility of a SANE exam with the resident or his representative. Additionally, the administrator did not interview the resident's attending physician, staff members, or other relevant individuals to investigate the allegations. This lack of action placed residents at risk of undetected abuse and compromised their feelings of safety and well-being.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of rape made by a resident, identified as Resident #11, who had a history of making false allegations. Despite the resident's cognitive assessment indicating intact cognition, the facility did not provide evidence of investigations into multiple allegations of rape. The resident had a complex medical history, including paraplegia, traumatic brain injury, and several mental health disorders, which may have contributed to his claims. However, the facility's care plan noted a history of false allegations, and interventions included reorientation and reassurance. Interviews and record reviews revealed that the facility did not follow its policy for investigating and reporting abuse allegations. The Administrator did not report the allegations to the appropriate authorities, nor did he document the investigation process or inform the resident's representative. The facility also failed to conduct interviews with relevant staff, the resident's physician, or other residents who might have been involved. This lack of action placed residents at risk of undetected abuse and psychosocial harm. The facility's policy required immediate reporting and thorough investigation of abuse allegations, but these procedures were not followed. The Administrator's failure to report the allegations promptly and conduct a comprehensive investigation led to the identification of an Immediate Jeopardy situation. The facility's records did not show any self-reports of the allegations until after the surveyors' intervention, highlighting a significant deficiency in the facility's handling of abuse allegations.
Unsafe Room Conditions Due to Air Conditioner Placement
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents, leading to potential risks for falls and discomfort due to overheating. Resident #13, a female with a diagnosis of Paralytic syndrome and Multiple sclerosis, required substantial assistance with daily activities and used a wheelchair for mobility. Her room had a portable air conditioning unit placed in front of her closet door, obstructing access to her clothing. This placement forced her to move the unit, which was difficult due to her right-sided paralysis, making it inconvenient to access her clothes. Resident #17, a female with End stage renal disease, Heart Failure, and Type 2 diabetes, also required moderate assistance with daily activities and used a wheelchair. Her room had an electrical cord running from the air conditioner across her closet door, obstructing access. She and the staff had to unplug the cord to access the closet, causing the room to become warm when the air conditioner was disconnected. This setup was inconvenient and potentially unsafe. Resident #63, a male with chronic kidney disease, Type 1 diabetes, and Hypertension, was at high risk for falls and required assistance with ambulation. His room had an air conditioner cord draped across the closet door, obstructing access and creating a trip hazard. He had to unplug the cord to access his closet, occasionally forgetting to plug it back in, leading to a warm room. Interviews with staff, including an LVN and the Maintenance Director, confirmed the unsafe setup of the air conditioning units and acknowledged the potential risks posed by the cords obstructing closet access.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in nutrition, grooming, and personal hygiene. Resident #79, who is blind and has multiple health conditions including schizoaffective disorder and idiopathic aseptic necrosis, was not provided with the required assistance during meals as outlined in his care plan. Despite needing total assistance to eat, staff left him alone with his meal tray, resulting in frustration and a sense of neglect. Observations revealed that Resident #79 was left to eat with his hands and without proper setup, leading to incidents where he struggled to locate his food and even fell while attempting to manage his meal tray. Residents #66 and #68 were not provided with regular showers as per their care plans. Resident #66, who has congestive heart failure and diabetes, received only three showers over a 29-day period, despite needing supervision or assistance. Resident #68, who has severe cognitive impairment and requires assistance with bathing, did not receive any showers during a similar timeframe. This lack of personal hygiene care was confirmed by interviews with Resident #66 and a family member of Resident #68, who noted the resident's unclean condition. The facility's policies on meal assistance and the red napkin program, intended to identify residents needing feeding assistance, were not effectively implemented. The Director of Nursing acknowledged that Resident #79 should not have been left alone with his meal tray and expressed concern over the lack of assistance provided. The failure to adhere to care plans and facility policies resulted in unmet needs for these residents, potentially impacting their dignity and emotional well-being.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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