Duncanville Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Duncanville, Texas.
- Location
- 419 S Cockrell Hill Rd, Duncanville, Texas 75116
- CMS Provider Number
- 676178
- Inspections on file
- 79
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Duncanville Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with COPD, ADHD, insomnia, Type 2 diabetes, and bipolar disorder, who was cognitively intact, received two involuntary discharge notices, but the facility did not send copies of these notices to the State LTC Ombudsman as required by its own transfer/discharge policy. Record review showed no documentation that the Ombudsman was notified, and the Ombudsman confirmed she had not received notice of either discharge. The Social Worker reported she was unaware of a requirement to notify the Ombudsman, while the Regional President of Operations stated the Ombudsman should receive a copy of discharge notices. The Business Office Manager acknowledged that notifying the Ombudsman was her responsibility and that she failed to do so when both discharge notices were issued.
A resident with dementia, muscle wasting, malnutrition, type 2 DM, and vertigo, who was totally dependent on staff for toileting per MDS and care plan, did not receive timely incontinence care. The CNA assigned to the resident reported the last change occurred before breakfast and acknowledged not returning to provide further care due to other tasks, despite a facility expectation of incontinence care every 2 hours and PRN. The RN and DON confirmed that nursing staff, including charge nurses, were responsible for 2-hourly checks and changes, but the RN stated she was too busy to check this resident. This resulted in the resident going at least 5 hours without incontinence care, contrary to the facility’s ADL policy and stated practices.
A resident with hemiplegia, prior cerebral infarction, type 2 DM, muscle weakness, and muscle wasting, and with severe cognitive impairment and extensive ADL dependencies per the MDS, did not have ADLs addressed as a focus of care in the comprehensive care plan. Interviews with the MDS Coordinator, DON, and Administrator confirmed that the nurse management team and MDS staff were responsible for developing and updating care plans, that ADLs were recognized as important to guide care, and that care plans were reviewed periodically and as needed, yet no ADL interventions were included for this resident despite facility policy requiring comprehensive, person-centered care plans with measurable objectives, timeframes, and specified services.
A resident with hemiplegia, severe cognitive impairment, and type 2 diabetes, who required substantial/maximal assistance for personal hygiene, was observed with overgrown fingernails and reported that no one would cut them. The resident’s care plan did not address ADLs, and staff interviews showed that while CNAs and a shower aide trimmed nails on shower days, nurses were designated to perform nail care for diabetic residents. An RN reported she was unaware the resident was diabetic and focused on skin rather than nail care, while the DON and an LVN stated nurses were responsible for trimming diabetic residents’ nails as needed and at least weekly. This was inconsistent with the facility’s ADL policy, which required provision of grooming and personal hygiene services for residents unable to perform ADLs independently.
A resident with acute kidney failure, COPD exacerbation, muscle weakness, severe cognitive impairment, and frequent incontinence received incontinent care during which a CNA failed to follow the facility’s infection control and hand hygiene policy. The CNA removed soiled gloves after cleaning urine and a small bowel movement, then donned clean gloves taken from her uniform pocket without performing hand hygiene between glove changes, and proceeded to apply a clean brief. In interviews, the CNA and an RN confirmed that facility policy requires hand hygiene before and after glove use, glove changes with hand hygiene between dirty and clean tasks, and obtaining gloves from room glove boxes rather than carrying them in pockets.
Staff did not ensure that all residents at the same dining table were served meals simultaneously, resulting in two residents having to wait while another ate, which caused discomfort and was acknowledged as inappropriate by staff. Additionally, a resident with quadriplegia repeatedly found her bed unmade until late in the day, despite requests and facility policy requiring beds to be made before lunch. These failures affected residents with significant medical needs and were confirmed through observation and staff interviews.
A medication aide failed to perform hand hygiene between direct contact with multiple residents while serving meals, despite available hand sanitizer and prior education. The residents involved had significant medical conditions and required assistance with daily living. The DON confirmed that staff are required to follow hand hygiene protocols, but no recent in-services had been conducted.
A resident with a colostomy did not receive timely assistance with changing their colostomy bag upon request, resulting in prolonged periods with a full or leaking bag and stained clothing. Staff interviews confirmed that only nurses could change colostomy bags, and delays in response were common, sometimes lasting an entire shift. The DON and administrator acknowledged that such delays could impact resident dignity and care, and the facility's colostomy care policy was not provided during the survey.
A resident with multiple medical and cognitive conditions, who was on hospice care, tied a call light cord around his neck. The incident was not reported to the State Survey Agency within the required timeframe, and no incident report or internal investigation was completed, despite facility policy and regulatory requirements.
A resident with severe cognitive impairment and a full code status was found unresponsive, but the assigned RN failed to initiate CPR or call 911 despite being informed by family and staff of the resident's code status. Another RN eventually began CPR after a delay, and the resident was transported to the hospital by EMS but later expired. The deficiency was due to the RN's failure to follow established protocols and physician orders.
A registered nurse worked without a valid license after it had expired, due to the facility's failure to conduct required monthly license verifications and annual background checks. The issue was discovered through a state board of nursing check, and the responsible HR staff and administrator were unaware of the lapse until after the fact.
Ten dinner trays with leftover food and trash were left in the dining hall overnight and not removed before breakfast, resulting in an unclean environment as residents arrived for their morning meal. A resident expressed concern about clutter and pests, while dietary staff and management acknowledged the oversight and its potential impact on cleanliness and food safety.
Surveyors found that food items in the kitchen were not consistently labeled, dated, or sealed, with moldy produce, improperly covered containers, and a dented can present. Staff interviews revealed uncertainty about cleaning routines and inconsistent adherence to food safety policies, resulting in food storage and handling practices that did not meet professional standards.
A resident with a history of PAD, diabetes, and hypertension, who was cognitively intact, reported that $611.00 was taken from her after a medication aide and the aide's family member became involved in a personal financial transaction following the resident's discharge. The aide shared the resident's contact information with her family member, who then facilitated the withdrawal of funds for an apartment deposit that was never returned. The administrator, when informed, did not act, citing the resident's discharge status, and the facility could not provide a relevant confidentiality policy.
A resident with hemiplegia and a history of stroke reported being physically abused by another resident, an incident witnessed by the DON. Although the DON notified the Administrator (Abuse Coordinator) within an hour, the required report to state authorities was not made within the mandated two-hour window. The Administrator was unable to provide documentation of a timely report, and the facility's policy requiring prompt reporting was not followed.
A resident with unsteadiness on feet experienced multiple falls without injury, but the facility failed to update the care plan with new interventions in a timely manner. Despite the falls, no changes were made to the resident's environment, such as adding floor mats or adjusting bed height. Staff interviews highlighted the importance of updating care plans within 24 to 48 hours after a fall to prevent further incidents.
A LTC facility failed to provide proper pharmaceutical services, resulting in medication administration errors for three residents. An LVN administered medications via a gastrostomy tube against physician orders, crushed medications that should not be crushed, and gave insulin labeled for another resident. An MA failed to administer the correct dosage of liquid Potassium Chloride and did not mix MiraLAX with the correct amount of water. These actions violated medication administration protocols and put residents at risk.
A CNA failed to perform hand hygiene after direct contact with multiple residents during meal service, violating the facility's infection control program. This lapse involved residents with various medical conditions, including cognitive impairments and chronic illnesses. Despite training, the CNA did not sanitize hands between interactions, risking cross-contamination.
A resident with multiple serious health conditions requested to be sent to the hospital during dialysis, but the facility staff did not honor the request, citing the need for corporate approval. Despite stable vital signs, the resident's dissatisfaction and potential risk were noted. Interviews revealed unclear facility policies regarding hospital transport requests.
The facility failed to maintain food safety standards, with unclean equipment, improper food labeling, and inadequate hand hygiene practices observed. Staff did not consistently wash hands or change gloves, risking cross-contamination. Food items lacked proper labeling and were stored past expiration dates, and dented cans were not separated, increasing the risk of food-borne illnesses.
A resident with severe cognitive impairment was found with long, discolored fingernails and scratches on his forehead, indicating a failure in maintaining personal hygiene. Despite requiring extensive assistance with ADLs, the care plan did not reflect any resistance to nail care. Staff interviews confirmed regular showers but noted occasional resistance to nail trimming. The facility lacked documentation of a nail care policy.
A resident with severe cognitive impairment was found with superficial scratches on the forehead, which were not documented or assessed by the facility staff as required by protocol. Despite being informed, an LVN did not evaluate the scratches, and no incident report or 24-hour report notation was made, deviating from the facility's policy and placing the resident at risk.
A resident with multiple health conditions was served cold and improperly cooked food, despite having filed a grievance about meal temperatures. The LVN did not offer to warm the food, and a group of residents confirmed that meals were often served cold. The facility's administrator was aware of the issue but did not ensure it was resolved.
A resident with a documented allergy to milk products did not consistently receive lactose-free milk, leading to discomfort and dissatisfaction. Despite grievances and requests, the dietary staff failed to provide the necessary dietary accommodations, and the issue persisted until the administrator intervened.
A resident with dementia and on anticoagulant therapy had superficial scratches on his forehead that were not documented or assessed by facility staff. Despite being observed by a CNA, the scratches were not recorded in the resident's medical records or reported in the facility's 24-hour report. Interviews revealed that staff did not adhere to the facility's policy for documenting changes in a resident's condition, leading to a deficiency in maintaining accurate clinical records.
A facility failed to ensure proper storage and administration of medications, as an LVN left a medication cart unlocked and preset medications, including a controlled substance, for a resident with quadriplegia and chronic pain. The DON confirmed that carts should be locked when not in sight and medications should not be preset, per facility policy.
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours, despite the resident having multiple care needs. Both the DON and the Administrator were unsure why the plan was not completed, which is required by the facility's policy.
The facility failed to ensure that Medication Cart #1 was locked when unattended, posing a risk of unauthorized access to medications. Nurse C left the cart unlocked for three minutes, and both Nurse C and the DON acknowledged the associated risks. Facility policy mandates that all drugs and biologicals be stored in locked compartments accessible only to authorized personnel.
Failure to Notify State LTC Ombudsman of Involuntary Discharge Notices
Penalty
Summary
The deficiency involves the facility’s failure to send copies of involuntary discharge notices to the State LTC Ombudsman as required by facility policy and regulation. A female resident with COPD, ADHD, insomnia, Type 2 diabetes, and bipolar disorder, cognitively intact with a BIMS score of 14, was admitted on a prior date and later received two involuntary discharge notices dated 03/19/26 and 04/22/26. Record review of the resident’s progress notes and electronic health record from 03/19/26 to 04/30/26 showed no documentation that a written notice of discharge and reasons for the move were provided to the Ombudsman. The facility’s written “Transfer or Discharge Notice” policy, reviewed and revised 03/03/26, stated that a copy of the notice is to be sent to the Office of the State LTC Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. During interviews, the Ombudsman reported that she did not receive notification from the facility regarding discharges and confirmed that the resident had received an involuntary 30‑day discharge notice in March 2026, but because it was past the 30‑day appeal window, she was unable to assist; she also stated she was not notified of the second discharge notice. The Social Worker stated she was unaware that the Ombudsman had to be notified prior to resident discharge and believed her responsibility was limited to notifying residents, responsible parties, and physicians. The Regional President of Operations stated that discharge notices were to be given to residents or their responsible parties and that the Ombudsman was also to receive a copy. The Business Office Manager acknowledged that the Ombudsman was not notified when either discharge notice was issued to the resident and stated that this omission was an error on her part, despite her understanding that the Business Office Manager was responsible for notifying the Ombudsman. The Administrator was unavailable for interview during the investigation.
Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically toileting and incontinence care, for a dependent resident. The resident was an elderly female with dementia, muscle wasting and atrophy, unspecified protein-caloric malnutrition, type 2 diabetes, and bilateral benign paroxysmal vertigo. Her quarterly MDS showed she was unable to complete the BIMS interview and was dependent on staff for toileting, and her care plan documented an ADL self-care performance deficit with total dependence on one staff member for toilet use. Facility policy on ADLs required appropriate support and assistance with elimination and toileting for residents unable to carry out ADLs independently. On the day of the survey, the resident reported, through an account manager translating, that she believed she had not been changed that day and that no one had asked if she needed to be changed. The CNA assigned to her stated that incontinence care was to be provided every two hours or as needed and acknowledged that the resident was last changed before breakfast and was not changed again because the CNA was occupied giving bed baths and getting other residents up. The RN stated that incontinent care was to be provided every two hours and PRN, and that charge nurses were responsible for checking residents every two hours, but admitted she was busy and did not check this resident for incontinence care. The DON confirmed the expectation that CNAs check and change residents every two hours and that charge nurses ensure this through rounding, and stated that delayed incontinence care placed residents at risk for infection, skin breakdown, dignity issues, and pain from sitting.
Failure to Include ADL Interventions in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of a comprehensive, person-centered care plan for a resident with significant medical and functional needs. Record review showed the resident was an older male with hemiplegia, cerebral infarction, type 2 diabetes, muscle weakness, and muscle wasting/atrophy. A quarterly MDS dated 03/29/2026 documented a BIMS score of 7, indicating severe cognitive impairment, and Section GG0103 showed the resident required substantial/maximal assistance for oral hygiene, toileting, personal hygiene, lower body dressing, and footwear, was dependent for showers/baths, needed partial/moderate assistance for upper body dressing, and setup/clean-up assistance for eating. Despite these documented ADL dependencies, review of the comprehensive care plan on 04/07/2026 revealed that ADLs were not addressed as a focus of care. During interviews, the MDS Coordinator stated that MDS staff were responsible for care plans, that care plans were reviewed quarterly and as needed by the IDT, and that ADLs were important for staff to know how to care for residents, but she was unaware that ADLs were excluded from this resident’s care plan. The DON reported that the nurse management team, including the ADON, MDS Coordinator, and nurses, created and carried out care plans, that ADLs were important to guide staff on residents’ care needs, and that care plans were reviewed quarterly and as needed, but she did not know why ADLs were missed. The Administrator stated that care plans were updated as residents progressed or had changes in condition, that ADLs were reflected in the care plan after 21 days, and that care plans were updated quarterly and at any time by the MDS Coordinator and DON. Review of the facility’s “Care Plans, Comprehensive Person-Centered” policy dated 06/02/2025 showed that comprehensive care plans were required to include measurable objectives, timeframes, and descriptions of services to attain or maintain the resident’s highest practicable well-being, which was not met for this resident’s ADL needs.
Failure to Provide Nail Care and ADL Support for Dependent Diabetic Resident
Penalty
Summary
The facility failed to provide necessary ADL services to maintain grooming and personal hygiene for a male resident with hemiplegia, cerebral infarction, type 2 diabetes, muscle weakness, and muscle wasting/atrophy. His quarterly MDS showed a BIMS score of 7, indicating severe cognitive impairment, and Section GG0103 documented he required substantial/maximal assistance for personal hygiene. His comprehensive care plan, reviewed on 04/07/2026, did not address ADLs as a focus of care. During observation on 04/07/2026, the resident was seen in his wheelchair with long fingernails, approximately 1/8 inch, on his right hand, and he stated he wanted his fingernails cut but no one would cut them. Interviews with staff revealed that CNAs and the shower aide cut residents’ nails on shower days, but nurses were responsible for nail care for residents with diabetes. The CNA and shower aide both stated that nail care was done on shower days and that nurses were responsible for diabetic residents’ nails. An RN stated nurses were responsible for cutting fingernails of diabetic residents but said she was unaware this resident was diabetic and that she focused on skin care rather than nail care in her daily observations. The DON stated nurses were responsible for trimming diabetic residents’ nails as needed and were expected to know which residents were diabetic and provide necessary care as part of daily care. An LVN stated nurses were responsible for cutting diabetic residents’ nails on shower days and at least weekly. The facility’s ADL policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene, including hygiene and grooming, but this was not implemented for this resident’s nail care.
Failure to Follow Hand Hygiene and Glove Use Practices During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain its infection prevention and control program during incontinent care for one resident. The resident was an older male with acute kidney failure, COPD with exacerbation, muscle weakness, severe cognitive impairment (BIMS score 07), and was frequently incontinent of bowel and bladder. During an observation of incontinent care, a CNA entered the resident’s room, washed her hands, donned clean gloves, and assisted the resident from his wheelchair to the bed. She unfastened a urine-soaked brief that also contained a small bowel movement, cleaned the resident’s front area, and then helped him turn to his right side to clean his buttocks. After removing the soiled brief and placing it in a plastic bag, the CNA removed her gloves and then took a clean pair of gloves from her uniform pants pocket. The CNA put on the clean gloves without performing any hand hygiene between glove changes and then applied a clean brief and covered the resident. She removed her gloves, performed hand hygiene, and exited the room. In a subsequent interview, the CNA acknowledged she was required to perform hand hygiene before and after removing the dirty brief, to change gloves with hand hygiene after cleaning the resident and before applying a clean brief, and that she should not carry gloves in her pockets but obtain them from glove boxes in the room. She stated she forgot to bring hand sanitizer and recognized that not following hand hygiene and infection control policy could lead to cross contamination and infection. An RN interview confirmed that staff were expected to perform hand hygiene before and after care, to use hand sanitizer or wash hands when soiled, to change gloves and perform hand hygiene between dirty and clean tasks during incontinent care, and that gloves were supplied in each room and not to be carried in pockets. Review of the facility’s hand hygiene policy showed that hand hygiene is considered the primary means to prevent spread of infection, must be performed before and after applying non-sterile gloves, and that gloves do not replace hand hygiene.
Failure to Uphold Resident Dignity in Meal Service and Room Care
Penalty
Summary
The facility failed to treat several residents with respect and dignity, as required by resident rights policies. Specifically, staff did not ensure that all residents seated at the same dining table were served their meals at the same time. One resident was observed eating lunch while two other residents at the same table waited to be served, with one resident expressing discomfort at having to watch another eat before receiving her own meal. Another resident, who was nonverbal, indicated agreement with this sentiment through gestures. Staff interviews confirmed that the expectation is for all residents at a table to be served simultaneously, but this was not consistently practiced due to the way trays were distributed from the kitchen. Additionally, the facility failed to make up a resident's bed in a timely manner, despite repeated requests from the resident. The resident, who has quadriplegia and no cognitive impairment, reported that her bed was often left unmade until late in the day, sometimes as late as 6:00 p.m. or 8:00 p.m., which interfered with her preferred bedtime and caused her embarrassment when visitors arrived. Observations confirmed that the bed remained unmade well into the afternoon, and staff interviews revealed a lack of consistent follow-through on making beds before lunchtime, as required by facility policy. The residents involved had significant medical conditions, including heart failure, hypertension, diabetes, aphasia, stroke, depression, and quadriplegia. Despite these needs, the facility did not uphold their rights to a dignified environment and timely care. Staff and administration acknowledged awareness of the policies but did not ensure their consistent implementation, resulting in residents feeling their dignity was compromised.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by a medication aide's failure to perform proper hand hygiene while serving meals in the main dining room. Observations revealed that the aide, after washing her hands and adjusting her clothing, did not use hand sanitizer before serving lunch trays to multiple residents. The aide had direct contact with residents, including touching their hands and shoulders, and handled meal trays and utensils without performing hand hygiene between each interaction. Hand sanitizer was available in the dining room, but was not used by the aide during the meal service. Record reviews indicated that the residents involved had significant medical conditions, including heart failure, hypertension, diabetes, atrial fibrillation, and cognitive impairments, requiring varying levels of assistance with activities of daily living. Interviews with the aide confirmed she did not complete hand hygiene after resident contact, despite being educated on the procedure. The Director of Nursing acknowledged that staff are required to perform hand hygiene after resident contact and that supplies were available, but also stated that no in-services on hand hygiene had been conducted since her recent arrival at the facility. Facility policies required regular staff education and adherence to hand hygiene protocols to prevent the spread of infections.
Failure to Provide Timely Colostomy Care Upon Resident Request
Penalty
Summary
A deficiency was identified when a resident who required colostomy care did not receive timely assistance with changing their colostomy bag upon request. The resident, who had a history of intestinal obstruction, dysphagia, cognitive communication deficit, and gastrostomy status, reported to a state surveyor that he wanted his colostomy bag changed because it had not been emptied since the previous night and was starting to lift, raising concerns about potential leakage. The resident used the call light, and a facility aide informed the nurse of the request. However, the bag was not changed promptly, and the resident stated that the bag had leaked on his clothes before, though he could not recall the exact timing. Further evidence was provided by a complainant who observed the resident in bed with a leaking colostomy bag that had stained his clothing. The complainant witnessed an aide inform the nurse, but it took over two hours for the nurse to respond and change the bag, after which the aide cleaned the resident. A photograph submitted by the complainant showed visible stains on the resident's clothing. Interviews with CNAs confirmed that only nurses were permitted to change colostomy bags and that there were repeated delays in fulfilling resident requests, sometimes lasting an entire shift. CNAs expressed concerns that such delays could lead to leaks, skin irritation, and dignity issues for the resident. A nurse confirmed that the resident had requested a bag change but stated she had only burped the bag and planned to change it after the resident ate lunch, claiming the bag was not full and there was no immediate risk. Both the DON and the administrator stated that residents have the right to have their colostomy bags changed upon request and acknowledged that delays could result in dignity issues and potential harm. The facility's policy on colostomy care was requested but not provided before the survey exit.
Failure to Timely Report and Investigate Alleged Abuse/Neglect Incident
Penalty
Summary
The facility failed to ensure that all allegations involving abuse, neglect, or misappropriation were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency. Specifically, an incident involving a male resident with chronic diastolic heart failure, severe intellectual disabilities, and cognitive communication deficit, who was admitted to hospice, was not reported. The resident was found to have tied a call light cord around his neck, an event that was not communicated to the State Survey Agency as required by regulation. Interviews with facility staff, including the ADON, NP, previous DON, and the administrator, revealed that the resident had not previously expressed suicidal ideations or intentions to harm himself, and assessments did not indicate such risks. The incident occurred while hospice staff were still present in the building, and the resident was subsequently placed on one-to-one supervision and sent for psychological evaluation after expressing a desire to harm himself. However, there was no documentation of an incident report or an internal investigation being completed for this event. A review of facility records and policies confirmed that the incident was not reported in the TULIP system, and the facility's Abuse Prohibition Policy required notification of such events to proper authorities according to state and federal regulations. The administrator acknowledged that not completing an incident report and investigation could have placed residents at harm if signs were not recognized and acted upon in a timely manner.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility personnel failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, an elderly female with severe cognitive impairment, multiple diagnoses including dementia, and a terminal prognosis related to Alzheimer's disease, was admitted as a hospice patient. Her medical records, care plan, and physician orders indicated she was a full code, meaning she should receive resuscitation efforts in the event of cardiac or respiratory arrest. At the time of the incident, the resident's advance directive status was not updated to DNR, as the necessary documentation had not been signed by the responsible party or physician. On the day of the incident, the resident was found unresponsive by family members, who immediately notified the assigned RN. Despite being informed multiple times by family and other staff that the resident was a full code and required CPR, the RN failed to initiate life-saving measures. The RN did not check the resident's code status or follow the physician's orders and facility policy to begin CPR and call 911. Other staff, including a CNA and another RN, became involved after being alerted to the situation. The second RN ultimately initiated CPR, but only after a significant delay and after being verbally notified by the CNA. There was no announcement of a code blue over the PA system, and the initial RN left the room before EMS arrived, failing to communicate with emergency personnel about the resident's condition and care provided. Interviews with staff and review of documentation confirmed that the RN responsible did not follow established protocols for determining code status and initiating emergency response. The failure to provide timely CPR and activate emergency procedures was corroborated by multiple witnesses, including family members, other nursing staff, and hospice personnel. The resident was eventually transported to the hospital by EMS, but later expired. The deficiency was identified as a result of the RN's inaction and lack of adherence to the resident's documented wishes and medical orders.
Failure to Ensure Nursing Staff Maintained Current Licensure
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) maintained a current and valid nursing license in accordance with state laws and regulations. Record review and interviews revealed that the RN's license had expired, and the facility did not verify or identify the lapse in licensure. The Human Resources (HR) staff member responsible for conducting monthly license verifications and annual background checks was unaware of the expired license and had not completed the required checks for the RN during the current year. The RN continued to work as a full-time charge nurse and later as PRN without a valid license until termination. The Administrator (ADM) was not aware of the RN's expired license and believed all nursing licenses were current. The ADM stated that if he had known about the expired license, the RN would have been suspended until renewal. The facility did not provide a policy for review regarding license verification. The deficiency was confirmed through the state board of nursing's online verification, which showed the RN's license as expired. No information was provided regarding any residents directly affected by this deficiency.
Failure to Remove Used Dinner Trays Results in Unclean Dining Hall Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the dining hall by not removing ten dinner trays with food and trash from the previous evening before breakfast the next morning. During an observation, these trays were found on tables and a cart in the dining hall while approximately eight residents were present awaiting breakfast. A resident reported that trays from the previous night were sometimes left out and expressed concern about clutter and the potential for pests. Interviews with dietary staff and the interim dietary manager revealed that evening staff were responsible for returning trays to the kitchen, but sometimes caregivers brought trays back to the dining hall after kitchen staff had left. In such cases, morning kitchen staff were expected to clear the trays before breakfast service. The interim dietary manager and the administrator acknowledged that leaving trays out could result in not having enough trays for breakfast, risk of cross contamination, pest attraction, and the possibility of residents consuming spoiled or contaminated food. Review of the facility's policy confirmed residents' rights to a safe and appropriate living environment.
Failure to Properly Store, Label, and Seal Food in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and handling of food. Specifically, food items in the refrigerator, freezer, and pantry were found to be improperly labeled, undated, and unsealed. Moldy sweet potatoes and cucumbers, an unlabeled and loosely covered container of mixed fruit, chopped chicken in an unsealed bag, and other improperly stored items were noted. Additionally, a dented can of black eye peas was found in dry storage, and a single-serve cup of orange sherbet in the freezer was not properly sealed. Staff interviews confirmed that all dietary staff were responsible for labeling, dating, sealing, and checking for spoiled foods, but there was uncertainty about the frequency of cleaning and removal of expired or spoiled items. The facility's policy required all food items to be labeled, dated, and properly sealed, with dented cans and expired foods to be removed from storage. However, observations and staff interviews revealed these procedures were not consistently followed. The Interim Dietary Manager, who was only present part-time, was unsure of the facility's routine practices, and staff acknowledged the risks of contamination and cross-contamination due to these lapses. The facility's practices were not in accordance with professional standards or the FDA Food Code requirements for food safety and date marking.
Failure to Protect Resident from Exploitation and Misappropriation of Property
Penalty
Summary
A deficiency occurred when a resident reported that $611.00 was taken from her following interactions with a medication aide (MA) and the MA's family member. The resident, who had diagnoses including peripheral arterial disease, type 2 diabetes mellitus without complications, and essential hypertension, was cognitively intact at the time of the incident. While residing at the facility, the resident befriended the MA, who obtained her personal phone number. After the resident was discharged, the MA contacted her regarding renting an apartment, and the MA's family member drove the resident to the bank to withdraw $611.00 for an apartment deposit. The resident provided the money and received a signed note from the MA's family member acknowledging the deposit. Subsequently, the apartment arrangement fell through, and the resident was unable to recover her funds despite repeated attempts to contact the MA. The administrator (ADM) was made aware of the incident but did not take further action, stating that the event occurred after the resident's discharge and did not believe the facility was responsible. The MA admitted to sharing the resident's phone number with her family member and acknowledged the relationship between her family member and the resident. The facility was unable to provide a policy related to the confidentiality of resident information or employee violations when requested. The report documents that the facility failed to protect the resident from exploitation and did not ensure the resident's right to be free from misappropriation of property.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving two residents, as required by Texas law and facility policy. Specifically, a resident with hemiplegia and a history of stroke, who was cognitively intact, reported being physically abused by another resident. The incident, witnessed by the DON, involved one resident grabbing another by the jacket around her shoulder. The DON reported the incident to the Administrator, who serves as the Abuse Coordinator, within an hour. However, the Administrator did not report the allegation to the state agency within the required two-hour timeframe. Instead, the initial report was delayed, and there was confusion regarding the date of the incident and the method of reporting, with the Administrator unable to provide documentation of a timely report. Record review showed that the facility's notification to the state agency was not sent until two days after the incident, and the provider investigation report was also delayed. Interviews with staff revealed a lack of clarity regarding the reporting timeframe, with the DON believing the requirement was 24 hours rather than two. The facility's policy clearly states that allegations of abuse must be reported within two hours, but this protocol was not followed in this case, resulting in a deficiency for failure to timely report suspected abuse.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, specifically following incidents of falls. The resident, a male with a diagnosis of unsteadiness on feet, experienced multiple falls without injury during his stay. Despite these incidents, the care plan was not updated with new interventions until over a month later, which could potentially place residents at risk of not addressing individualized needs and services. The resident had two falls on specific dates, and no interventions were entered into his care plan following these events. Interviews with the resident revealed that he did not notice any changes in his room, such as the addition of floor mats or adjustments to the bed height, after his falls. The care plan was eventually updated, but not in a timely manner, as it was revised only after the third fall occurred. Interviews with facility staff, including CNAs, the ADON, and the Regional RN, highlighted the importance of updating care plans promptly to prevent further incidents. The staff indicated that care plans should be updated within 24 to 48 hours after a fall to ensure that appropriate interventions are in place. The facility's policy also emphasized the need for ongoing assessments and revisions of care plans as residents' conditions change.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents, leading to significant medication administration errors. A Licensed Vocational Nurse (LVN) administered medications to a resident via a gastrostomy tube without following physician orders, which specified oral administration. The LVN also failed to check the placement of the gastrostomy tube or check for residuals before administering the medications. Additionally, the LVN crushed medications that should not have been crushed, including Potassium ER and pantoprazole DR, potentially altering their effectiveness and causing harm. Another resident did not receive the correct dosage of liquid Potassium Chloride due to a medication spill that was not properly addressed by a Medication Aide (MA). The MA also failed to mix MiraLAX powder with the correct amount of water as per the physician's orders, leading to uncertainty about the actual dosage administered. These actions demonstrate a lack of adherence to medication administration protocols, putting the resident at risk of not receiving the intended therapeutic benefits. Furthermore, the LVN administered insulin labeled for a different resident to a third resident, which is a direct violation of medication administration policies. The Director of Nursing (DON) acknowledged that insulin should only be given to the patient it was prescribed for, and the Pharmacist Consultant highlighted the potential gastrointestinal harm from crushing certain medications. Despite these acknowledgments, the facility's staff failed to follow established procedures, resulting in multiple medication errors.
Inadequate Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA A, who did not perform hand hygiene after direct contact with four residents while serving meals. This lapse in protocol was observed during meal service on Hall 300, where CNA A interacted with residents without using gloves or sanitizing hands between each resident interaction. The failure to adhere to hand hygiene practices could lead to cross-contamination and the spread of infections among residents. Resident #1, a male with moderate cognitive impairment and diagnoses including anemia, hypertension, and heart failure, required assistance with activities of daily living. Resident #2, a female with severe cognitive impairment and diagnoses of diabetes, schizo-affective schizophrenia, and hypertension, also required staff assistance. Resident #3, a female with hypertension, malnutrition, and anemia, was cognitively intact but needed assistance with daily activities. Resident #4, a male with severe cognitive impairment, dementia, and muscle wasting, required staff assistance as well. CNA A's failure to perform hand hygiene after contact with these residents was a direct violation of the facility's infection control policies. During an interview, CNA A admitted to not completing hand hygiene due to being nervous and wanting to serve meals quickly to prevent them from getting cold. The interim DON confirmed that all staff were trained to perform hand hygiene before and after resident contact, and that failure to do so could spread germs. The facility's policy emphasized hand hygiene as the primary means to prevent infection spread, requiring staff to sanitize hands between each tray service. Despite receiving training, CNA A did not adhere to these protocols, leading to the identified deficiency.
Failure to Honor Resident's Request for Hospital Transport
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the resident's choices. A resident, who was moderately impaired and his own responsible party, requested to be sent to the hospital during a dialysis session because he felt unwell. Despite his request, the facility staff did not send him to the hospital, citing the need to contact the nurse practitioner and corporate office for approval, which was not obtained. The resident's medical history included serious conditions such as Hypertensive Heart and Kidney Disease with Heart Failure, End Stage Renal Disease, and Type 2 Diabetes, among others. On the day of the incident, the resident expressed feeling sick and requested hospital transport, but the weekend supervisor instructed the LPN to wait for corporate approval. The LPN attempted to contact the nurse practitioner and the resident's family, who also advised waiting. Despite the resident's stable vital signs, his request to go to the hospital was not honored, leading to dissatisfaction and potential risk. Interviews with facility staff revealed a lack of clarity in the facility's policy regarding sending residents to the hospital upon request. The DON stated that residents should be sent to the hospital if requested, without waiting for a doctor's approval, to avoid violating resident rights. However, the Executive Director noted that the facility's policy was vague, and the staff attempted to handle the situation in-house first. The ADON later stated she did not recall being asked about the situation, and the facility's policy on calling 911 was reviewed, highlighting the need for clearer guidelines.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. The ice machine chute guard was found to be unclean, with a light pink stain across its length. Additionally, the handwashing sink had smudges and food particles, and the garbage receptacle contained items other than paper towels. The facility also failed to maintain proper labeling and storage of food items in refrigerators, freezers, and dry storage. Many items lacked labels indicating the item description, received by date, opened date, and consume by or expiration dates. Some items were stored past their expiration dates, and others were left open to air, increasing the risk of contamination. The facility's staff did not consistently practice proper hand hygiene and use of personal protective equipment (PPE). Observations revealed that staff members, including cooks and dietary aides, frequently handled food and kitchen equipment without washing their hands or changing gloves after touching potentially contaminated surfaces. This included instances where staff members touched their masks, sneezed into their hands, and then continued food preparation without proper sanitation measures. Such practices could lead to cross-contamination and pose a risk of food-borne illnesses to residents. Furthermore, the facility did not have a separate area for storing dented cans, which were found mixed with undented cans. This oversight could lead to the use of compromised food products. The facility's Nutrition Services Food Storage Policy, revised in December 2020, was not followed, as evidenced by the lack of proper labeling and storage practices. The U.S. FDA Food Code 2022 guidelines were also not adhered to, as food items were not consistently labeled with the common name, preparation date, or expiration date, and were not stored according to the first in/first out basis. These deficiencies in food safety practices could place residents at risk for food-borne illnesses and cross-contamination.
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. Resident #19, a male with severe cognitive impairment due to dementia and anxiety, was observed with long, discolored fingernails and superficial scratches on his forehead. The resident required extensive assistance with ADLs and was not resistive to nail care according to his care plan. However, his nails were not trimmed or cleaned, which could have contributed to the scratches on his forehead. Interviews with staff revealed that the resident received regular showers and was non-combative, but sometimes did not like to have his nails trimmed. Despite this, the care plan did not reflect any resistance to nail care. The facility's administration acknowledged the importance of attending to residents' ADLs, including nail care, to prevent potential dignity issues and infection risks. However, there was no documentation of a nail care policy provided during the review.
Failure to Document and Assess Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This deficiency was identified when a CNA did not note superficial scratches on the resident's forehead during a morning observation. The resident, who has severe cognitive impairment and requires extensive assistance with activities of daily living, was observed with scratches that had dried blood, yet these were not documented or reported as required by the facility's protocol. Later in the day, an LVN was informed about the scratches but did not assess them, citing time constraints due to end-of-shift responsibilities. Despite being notified, the LVN did not document the scratches in the resident's progress notes or the facility's 24-hour report, which is used to communicate changes in residents' conditions. The lack of documentation and assessment of the scratches was a deviation from the facility's policy, which mandates immediate assessment and documentation of any new skin conditions. Interviews with various staff members, including CNAs and RNs, revealed that the facility's protocol requires any change in a resident's skin condition to be reported and documented. However, in this case, the protocol was not followed, as evidenced by the absence of any incident report or notation in the 24-hour report. This oversight placed the resident at risk for potential complications, as the scratches were not promptly assessed or treated according to the facility's standards.
Failure to Serve Food at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that food and drink were served at a palatable, attractive, and appetizing temperature for a resident reviewed for food and nutrition. The resident, a cognitively intact female with multiple diagnoses including stroke, seizures, depression, diabetes, and bipolar disorder, was served cold eggs and cream of wheat for breakfast, which she attempted to eat but found unappetizing. Additionally, during lunch, she was served a half-cooked baked potato, which she could not eat. The resident had previously filed a grievance about cold food being served at meals. Interviews and observations revealed that the LVN who served the breakfast did not offer to warm the food, assuming the resident would not eat well anyway. A group meeting with ten residents confirmed that food was often served cold and was not as tasty as before. The facility's administrator acknowledged receiving grievances about cold food and had discussed the issue with the dietary manager, but did not follow up to ensure the problem was resolved. The facility's policy on resident rights emphasizes the importance of providing adequate and appropriate care and services, which was not adhered to in this instance.
Failure to Provide Lactose-Free Milk for Resident with Allergy
Penalty
Summary
The facility failed to provide food that accommodates the allergies and preferences of a resident, specifically lactose-free milk, despite the resident's documented allergy to milk products. The resident, who is cognitively intact and requires assistance with daily activities, reported ongoing issues with receiving lactose-free milk, which was not consistently available in the facility. The resident experienced discomfort from consuming regular milk due to the lack of lactose-free options, despite having raised grievances about the issue. Observations and interviews revealed that the dietary staff did not consistently have lactose-free milk available, and the dietary manager did not respond to the resident's requests. The resident had previously informed the administrator about the issue, but no effective action was taken to ensure the availability of lactose-free milk. The dietary aide confirmed that lactose-free milk was not always available, and it was only obtained when the administrator intervened. The facility's failure to provide lactose-free milk as per the resident's dietary needs and preferences was documented in a grievance filed by the resident. The grievance was acknowledged, but the corrective action to provide the product was not effectively implemented, leading to continued dissatisfaction and discomfort for the resident.
Failure to Document and Assess Resident's Skin Condition
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, identified as Resident #19, who had superficial scratches on his forehead. On the morning of July 8, a CNA observed the scratches but did not document them in the resident's medical records. Later that day, an LVN was informed of the scratches but did not assess them, as she was occupied with her end-of-shift report. The lack of documentation and assessment of the scratches was a deviation from the facility's protocol for reporting changes in a resident's condition. Resident #19, a male with dementia and anxiety, was noted to have severe cognitive impairment and required extensive assistance with activities of daily living. His care plan included daily skin inspections due to his anticoagulant therapy. Despite these requirements, the scratches on his forehead were not documented in his progress notes, incident reports, or the 24-hour report, which are essential for ensuring all nursing staff are aware of changes in a resident's condition. Interviews with facility staff revealed a lack of adherence to the facility's policy for reporting and documenting skin conditions. The CNA who gave Resident #19 a shower did not note any scratches, and the LVN did not have time to assess the scratches. The Director of Nursing confirmed that any change in a resident's condition should be reported and documented, highlighting a failure in the facility's processes to ensure resident safety and proper care.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional principles, specifically in locked compartments, and that only authorized personnel had access to the keys. This deficiency was observed when LVN A left a medication cart unlocked outside a resident's room, which was closed at the time. Additionally, LVN A was seen preparing medications, including a controlled substance, and placing them in a medication cup, which was then locked in the cart for an extended period before administration. This practice of presetting medications is against the facility's policy and could lead to medication misuse and diversion. Resident #28, who was alert and oriented with a BIMs score of 12, was the intended recipient of the preset medications. The resident had a history of quadriplegia, anxiety, constipation, and chronic pain, requiring multiple medications for management. The Director of Nursing (DON) confirmed that medication carts should always be locked when not in direct sight and that medications should not be preset, especially narcotics. The facility's policy on administering medications, revised in April 2019, mandates that medication carts be kept closed and locked when out of sight of the nurse or aide.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #1 within 48 hours of admission. The resident, a [AGE] year-old male, was admitted on an unspecified date and had multiple care needs, including dependency for eating, oral hygiene, toileting hygiene, showering/bathing, dressing, personal hygiene, mobility, sitting/standing, transferring, and required a wheelchair. Additionally, the resident had a g-tube, was cognitively impaired, always incontinent, had an external catheter, required tube feeding, and needed physical, occupational, and speech therapy. Despite these needs, the baseline care plan was not completed within the required timeframe, as confirmed by the Director of Nursing (DON) and the Administrator during interviews on 02/07/24. The DON and the Administrator both expressed uncertainty as to why the baseline care plan was not completed within 48 hours. The Administrator noted that the baseline care plan is a simple document that mainly requires checking yes or no on various items. The facility's policy, dated 10/23/23, mandates that a baseline plan of care to meet the resident's immediate health and safety needs be developed within 48 hours of admission. The failure to complete this plan within the specified timeframe resulted in a lack of documentation on what the resident needed, potentially affecting the quality of care provided to newly admitted residents.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that Medication Cart #1 was locked when unattended, which could place residents at risk of unauthorized access to medications and potential harm or drug diversion. During an observation and interview, it was noted that Medication Cart #1 was left unlocked and unattended in the 100 hall between specific rooms for an additional three minutes before Nurse C returned. Nurse C admitted she was unaware that she had left the cart unlocked and acknowledged the risk involved. The Director of Nursing (DON) also confirmed the risk of leaving the medication cart unlocked. A review of the facility's policy on the storage of medications revealed that all drugs and biologicals should be stored in locked compartments, accessible only to authorized personnel.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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