Ebony Lake Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brownsville, Texas.
- Location
- 1001 Central Blvd, Brownsville, Texas 78520
- CMS Provider Number
- 675635
- Inspections on file
- 30
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Ebony Lake Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with diabetes, hemiplegia, and moderate cognitive impairment, who was dependent for toileting and bed mobility, was found by CNAs to have new purple discoloration and dry, scratch-like areas on the trunk/back after a reported fall the previous day. An LVN assessed the area, documented the findings, and noted the resident’s statement that it resulted from the fall, but did not notify the physician, initiate a change in condition assessment, or ensure notification of the resident’s representative, believing the discoloration was part of the prior fall incident. The DON confirmed that no follow-up with the physician or change in condition/skin assessment was completed because the discoloration was considered related to the earlier fall, contrary to the facility’s policy requiring prompt notification of changes.
A resident with diabetes, hemiplegia, and moderately impaired cognition, assessed as dependent for ADLs and transfers, had a care plan that noted dependence on two staff for transfers but did not specify the need for a mechanical lift. Progress notes documented that CNAs found the resident on the floor after he rolled from the mattress during care. In interviews, an LVN, the MDS nurse, and the DON all stated the resident required a two-person mechanical lift transfer and that such requirements should be reflected in the care plan for CNA guidance, but the transfer type was missing despite established processes for timely, individualized care planning.
A resident with hemiplegia, hemiparesis, type 2 DM, and moderately impaired cognition had a care plan and MDS indicating dependence for toileting hygiene and a requirement for two-person assist with bed mobility. Despite this, one CNA performed bed mobility alone after being told by another CNA to wait, and the resident fell to the floor while attempting to grab the mattress as the sheet was pulled. An LVN later documented a scratch on the resident’s shoulder blade and, the following day, discoloration on the trunk/back after the resident reported pain, but did not contact the physician, considering it part of the prior fall. The DON stated staff must follow each resident’s plan of care for proper transfers and that failure to do so can result in injury, and facility policy required reporting and investigation of all incidents and accidents involving residents.
A resident with diabetes and hemiplegia, fully dependent on staff for toileting hygiene, received perineal care from two CNAs during which one CNA failed to perform required hand hygiene between glove changes. The CNA removed a soiled brief, changed gloves without washing or using hand sanitizer, cleaned the perineal area, then again changed gloves without hand hygiene, with both CNAs only washing their hands before and after the procedure. The CNA later acknowledged she should have sanitized or washed her hands between glove changes, and the DON confirmed facility expectations and CDC-based standards for hand hygiene during such care.
A resident with multiple neurologic and respiratory diagnoses and moderate cognitive impairment had a documented change in code status from full code to DNR, with a care plan and physician order reflecting DNR status. An OOH-DNR form was completed and signed by the resident’s representative and two witnesses, but the attending physician did not sign the form as required by the OOH-DNR instructions and the facility’s advance directive policy. Facility staff, including SS, the DON, and the Administrator, acknowledged the missing physician signature yet indicated the DNR would still be honored in-house, resulting in a deficiency related to improper completion of the OOH-DNR.
Two residents with complex medical conditions, including stroke, Parkinson’s disease, Alzheimer’s disease, toxic encephalopathy, diabetes, and heart disease, had no physician or NP notes entered in the electronic medical record over extended periods, despite nursing notes indicating that FNPs and NPs were in the facility, assessed the residents, made medication changes, and addressed high blood sugar and family requests. The DON and Administrator reported that providers were expected to document in the electronic system, typically via notes uploaded into the Miscellaneous tab, but they could not explain why no provider documentation appeared for these residents, contrary to the facility’s policy requiring complete, accurate, and timely clinical records.
Surveyors observed a medication cart on the 400 hallway left unlocked and unattended at the nurse’s station. A GVN responsible for the cart acknowledged that it contained resident medications and that he was expected to lock it whenever he walked away. The DON reported that multiple staff, including the DON and ADON, are responsible for ensuring carts are locked and confirmed the expectation that carts be secured when not in use. Facility policy states that medication carts must remain locked at all times when not in use.
A CMA left a medication cart computer screen unlocked, exposing a resident's picture and personal information, which was observed by surveyors. The CMA admitted to forgetting to lock the screen, and the DON confirmed that this action violated facility policy and HIPAA requirements for resident privacy and confidentiality.
A resident with multiple fractures and surgical staples did not have complete documentation in the medical record regarding the removal of her staples. Although orders were present and the procedure was reportedly performed, there was no record of who removed the staples, how many were removed, or how the resident tolerated the procedure, contrary to facility policy and professional standards.
A resident with hypertension and other complex conditions did not receive pharmaceutical services in accordance with physician orders, as staff failed to hold Cozaar when blood pressure was out of parameters and inaccurately documented medication administration on the MAR. Staff did not consistently notify nursing when medication was held or refused, and documentation did not reflect actual events, despite prior training and competency assessments.
A resident with hypertension and other serious conditions had a physician order for an antihypertensive medication to be held if blood pressure or pulse was below set parameters. On three occasions, medication aides either did not administer the medication due to low blood pressure or administered it and the resident spit it out, but all documented the medication as given on the MAR. None notified nursing staff as required, resulting in inaccurate and incomplete clinical records.
A facility failed to update a resident's care plan after their code status changed from DNR to Full Code. Despite the physician orders reflecting the new status, the care plan still indicated DNR, which was acknowledged as an oversight by the MDS Coordinator and DON. The facility's policy requires care plans to be revised upon status changes, but this was not followed, resulting in a discrepancy between the care plan and the resident's current needs.
A resident with severe cognitive impairment and respiratory needs did not receive proper care due to the facility's failure to change suction and oxygen supplies as required. Observations showed outdated and undated equipment, and staff interviews confirmed the supplies were not changed weekly as per protocol, risking infection. The facility lacked a physician order for changing these supplies, contributing to the deficiency.
A deficiency was observed in the hand hygiene practices of a kitchen staff member, Cook E, who failed to wash hands for the required 20 seconds after contamination events. This was noted during a kitchen tour, where Cook E washed hands for only 5 and 3 seconds on separate occasions. Interviews confirmed the facility's policy and the importance of proper hand hygiene to prevent cross-contamination and infection spread.
A facility failed to accurately document the administration of supplemental oxygen for a resident with dementia and heart failure. Despite observations of the resident receiving oxygen, the treatment administration record did not reflect this, leading to discrepancies in the medical records. Staff interviews confirmed the lack of documentation, and the facility did not provide a medication administration policy.
Failure to Notify Physician and Representative of Resident’s Change in Condition After Fall
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident, the resident’s physician, and the resident’s representative of a significant change in condition. The resident was an older male with type 2 diabetes mellitus and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side, who was dependent on staff for toileting and required two staff for bed mobility and repositioning. His quarterly MDS showed a BIMS score of 12, indicating moderately impaired cognition. On the evening of 4/10/26, an LVN documented that CNAs reported discoloration on the resident’s left lower back near the armpit while changing him. The LVN assessed the resident and observed dry, scratch-like areas with purple discoloration in that area, and the resident stated that this occurred because he had fallen the previous day. During interview, the LVN stated that the resident had complained of pain to the right side of his trunk/back on 4/10/26, and upon assessment she saw a discoloration about 5 inches long on the left side of the trunk/back. She reported that the resident told her he had fallen the day before, and she did not call the physician, did not initiate a change in condition assessment, and did not treat this as a new change because she believed the discoloration was part of the prior fall incident from 4/9/26 and that the discoloration appeared the next day. The DON similarly stated that the LVN did not follow up with the physician regarding the discoloration because it was considered part of the earlier fall and that a change of condition or skin assessment was not done for the same reason. These actions and inactions were inconsistent with the facility’s “Notification of Changes” policy, which requires prompt informing of the resident, consultation with the resident’s physician, and notification of the resident’s representative when there is a change requiring notification.
Failure to Include Mechanical Lift Transfer in Resident Care Plan
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive care plan that included measurable objectives and time frames to meet a resident’s mental and psychosocial needs and transfer needs. Record review showed that a male resident with type 2 diabetes mellitus and hemiplegia/hemiparesis following a cerebral infarction, with a BIMS score of 12 indicating moderately impaired cognition, was assessed as dependent for toileting hygiene and transfers. The resident’s care plan, dated 12/24/24, documented an ADL self-care performance deficit related to limited mobility, hemiplegia, and hemiparesis, and stated that the resident was dependent on two staff for transfers, but it did not specify the use of a mechanical lift. The facility’s policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified needs. Progress notes dated 4/9/26 documented that CNAs called an LVN to the resident’s room and the resident was found on the floor on his left side after rolling from the mattress while CNAs were providing care; assessment noted a scratch to the left lower shoulder blade without pain, bruising, or skin tear. During interviews, an LVN, the MDS nurse, and the DON each stated that the resident required a two-person mechanical lift transfer and that such transfer requirements should be included in the care plan for CNAs to reference. The LVN and MDS nurse confirmed that the resident’s care plan did not indicate the need for a two-person mechanical lift transfer, and the MDS nurse and DON stated they did not know why the transfer type was not included, despite acknowledging that MDS nurses are responsible for creating and updating individualized care plans within specified time frames and upon changes in condition.
Failure to Follow Two-Person Assist Care Plan During Bed Mobility Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure a resident remained free from accidents and hazards and did not provide adequate supervision and assistance during bed mobility, contrary to the resident’s care plan. The resident was an older male with type 2 diabetes mellitus and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side, with a BIMS score of 12 indicating moderately impaired cognition. His quarterly MDS and care plan documented that he was dependent on staff for toileting hygiene and required assistance from two staff members for bed mobility, including turning and repositioning in bed. Despite this, on the morning of 4/9/26, CNAs were providing care when the resident ended up on the floor; progress notes documented that upon entering the room, an LVN found the resident on his left side on the floor, with CNAs reporting that the resident grabbed the mattress and rolled over to the right side, landing on his right side. The LVN’s head-to-toe assessment noted a scratch on the left lower shoulder blade, with no pain, bruising, or skin tear at that time, and later x-rays showed no acute left rib fracture or pneumothorax. In an interview, the resident stated that one night he fell because only one CNA changed him when there was supposed to be two, and that when he tried to grab the mattress and the CNA pulled the sheet, he fell to the floor. He also stated that the CNA did not wait for the other CNA and that x-rays were ordered two days later. Another CNA reported that she knew the resident was a two-person assist, had told the other CNA to wait while she assisted another resident, and that the other CNA decided to perform the bed mobility alone. An LVN stated that the resident required a two-person assist for bed mobility and reported that on the day after the fall the resident complained of pain to the right side of his trunk/back, with observed discoloration about 5 inches long on the left side of his trunk/back; the LVN stated she did not call the doctor because she considered it part of the prior fall incident. The DON stated that staff should follow each resident’s plan of care for proper transfers and that failure to do so could result in injury to residents or staff. The facility’s incident and accident policy required staff to report, investigate, and review any accidents or incidents occurring or allegedly occurring on facility property involving residents.
Improper Hand Hygiene During Perineal Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper hand hygiene during perineal care for one resident. The resident was an older male with type 2 diabetes mellitus and hemiplegia/hemiparesis following a cerebral infarction, and was care planned and assessed as dependent on staff for toileting hygiene and bed mobility. During an observed perineal care procedure, two CNAs entered the resident’s room and placed supplies on the bedside table. CNA A washed her hands and donned a gown and gloves, then removed the resident’s soiled brief and discarded it. After removing her gloves, CNA A immediately donned a new pair of gloves without washing or sanitizing her hands. CNA A then cleaned the resident’s perineal area, removed those gloves, and again failed to wash or sanitize her hands before donning another pair of gloves. The observation further showed that CNA A and CNA B washed their hands only before and after the entire procedure, and not between glove changes or after contact with soiled items and the perineal area. In an interview, CNA A acknowledged she should have washed or sanitized her hands between glove changes and stated she forgot because she was nervous. The DON stated that staff should wash hands if gloves are visibly soiled or use hand sanitizer between glove changes, and that the DON and ADON are responsible for monitoring staff compliance with infection control. The facility’s infection prevention and control policy referenced maintaining a program consistent with accepted national standards, and CDC guidance cited in the report specifies that hand hygiene should occur before moving from a soiled body site to a clean body site on the same patient and immediately after glove removal.
Failure to Obtain Physician Signature on OOH-DNR Order
Penalty
Summary
The facility failed to ensure a resident’s right to formulate and implement an advance directive by not obtaining the physician’s signature on an Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order. The resident was an older female with diagnoses including nontraumatic intracerebral hemorrhage in the cortical hemisphere, other toxic encephalopathy, pneumonia due to inhalation of food and vomit, and Wernicke’s encephalopathy. Her Quarterly MDS showed a BIMS score of 09, indicating moderate cognitive impairment, with unclear speech and intermittent ability to understand and be understood. The comprehensive care plan identified the resident as DNR, initiated and revised on the same date, and a progress note documented that the resident’s representative requested a change from full code to DNR. The order summary also reflected a DNR order. The OOH-DNR form for this resident, dated the same day as the DNR order, contained the signatures of the resident’s representative and two witnesses but lacked the attending physician’s signature, as required by the OOH-DNR instructions and the facility’s policy on residents’ rights regarding treatment and advance directives. During interviews, the social services staff member, the DON, and the Administrator each acknowledged that the physician had not signed the OOH-DNR at the time, yet stated that the DNR would be honored in-house if an event occurred. The OOH-DNR instructions specified that the attending physician must sign the form and document the existence of the order in the permanent medical record, and that the order must be signed and dated by two witnesses and, when applicable, by the physician in the designated section. The absence of the physician’s signature on the OOH-DNR constituted the deficiency.
Missing Physician/NP Documentation in Electronic Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with accepted professional standards for two residents. For the first resident, an older male with multiple complex diagnoses including cerebral infarction with right-sided involvement, Parkinson’s disease, Alzheimer’s disease, end-stage renal disease on dialysis, and Type 2 diabetes mellitus, the electronic medical record lacked any physician or nurse practitioner documentation over an extended period. The resident’s MDS showed he was nonverbal, rarely/never understood or able to understand others, and was fully dependent for toileting, showering, and personal hygiene, with continuous bladder and bowel incontinence. Nursing progress notes documented that a family nurse practitioner (FNP) assessed the resident on several dates in January, February, and March and made medication changes and follow-up plans, but there were no corresponding physician or NP notes entered in the Progress Notes or Miscellaneous sections of the electronic record from 01/21/2026 through 03/24/2026. For the second resident, an older female with diagnoses including hypertension, Type 2 diabetes mellitus, heart disease, and other toxic encephalopathy, the facility similarly failed to maintain physician or NP documentation in the electronic record. Her MDS reflected a BIMS score of 9, indicating moderate cognitive impairment, with clear speech and usual ability to understand and be understood, and a need for substantial/maximal assistance with toileting and showering, along with frequent bladder and occasional bowel incontinence. A nursing progress note documented that an NP was in the facility, was notified of the resident’s high blood sugar and the family’s request to review and discontinue some medications, and that the NP acted on this request. However, there were no physician or NP notes in the Progress Notes or Miscellaneous sections for this resident from 02/21/2026 through 03/24/2026. Interviews with facility leadership confirmed that the absence of provider documentation in the electronic medical record was inconsistent with facility expectations and policy. The DON stated that physicians and NPs should have notes in the Progress Notes or Miscellaneous sections of the electronic chart, and that they typically wrote notes on paper which were then uploaded into the Miscellaneous tab. She acknowledged not knowing why the two residents’ charts lacked doctor or NP notes and stated that if such notes were not in the computer, the resident’s progress or status would not be shown. The Administrator similarly stated that there should be physician and NP notes in the electronic system and that providers were usually on their computers while in the facility, but she did not know how or why there were no notes for these two residents. The facility’s “Documentation in Medical Record” policy required that each resident’s record contain an accurate representation of the resident’s experiences, with complete, accurate, and timely documentation of assessments, observations, and services, completed at the time of service or by the end of the shift, and containing sufficient detail about the resident’s care and responses to care.
Unattended, Unlocked Medication Cart on 400 Hallway
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored and secured in accordance with professional standards for one of five medication carts, specifically the cart on the 400 hallway. During an observation at 6:07 PM, the 400 Hall nurse’s medication cart was found unlocked and unattended while positioned against the nurse’s station. When the surveyor notified GVN A, who was responsible for that cart, he then locked it. GVN A stated he was expected to lock the medication cart whenever he walked away from it and confirmed that the cart contained medications for residents on the 400 hallway. In an interview, GVN A acknowledged responsibility for the cart and recognized that if it was left unlocked, a resident could open a drawer and take medication not prescribed for them. In a separate interview, the DON stated that multiple staff, including the DON and ADON, were responsible for ensuring medication carts were locked and confirmed the expectation that staff lock the cart whenever they walk away from it. The DON stated that if the cart was left unlocked, a resident or visitor could grab medication from the cart and it could harm them. Review of the facility’s policy “Medication Carts and Supplies for Administering Meds,” dated 10/1/2019, showed that the medication cart is required to be locked at all times when not in use.
Failure to Protect Resident Privacy and Confidentiality of Medical Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records for 12 residents reviewed for residents' rights. During an observation, a CMA left a medication cart computer screen unlocked and exposed a resident's picture, making resident-identifiable information visible. The CMA acknowledged forgetting to lock the computer screen, which was recognized as a HIPAA violation. The Director of Nursing confirmed that staff are expected to lock computer screens to prevent exposure of resident information. Review of facility policy indicated residents have the right to privacy and confidentiality of their information.
Incomplete Documentation of Staple Removal Procedure
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was admitted with multiple fractures, including those of the left ulna, humerus, and pubis, following a fall. The resident had surgical wounds with staples in the left upper arm and wrist. Medical orders were present to remove the staples, and documentation indicated that the removal was authorized and signed off in the electronic medical record. However, there was no documentation in the resident's medical record specifying when the staples were actually removed, who performed the procedure, how many staples were removed, whether any were left, or how the resident tolerated the procedure. Interviews with nursing staff revealed uncertainty about who removed the staples, and the responsible wound care nurse was no longer employed at the facility. The resident's responsible party reported witnessing the staple removal by a male nurse, but this was not reflected in the clinical documentation. The facility's policy required that all assessments, observations, and services provided be documented in a timely and complete manner, including details of procedures such as staple removal. The lack of documentation for this procedure meant the resident's clinical record was incomplete and did not meet accepted professional standards, as required by facility policy and regulatory expectations.
Failure to Follow Medication Administration Parameters and Documentation Procedures
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate administration and documentation of medications for a resident with multiple complex diagnoses, including acute kidney failure, secondary malignancies, and hypertension. The resident had a physician's order for Cozaar (Losartan Potassium) with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 120 or the diastolic blood pressure (DBP) was less than 60, or if the pulse was less than 60. Despite these clear parameters, medication administration records (MAR) indicated that the medication was signed as administered on three separate days when the resident's blood pressure readings were below the ordered thresholds. Interviews with the medication aides (MAs) responsible for administering the medication revealed that on each occasion, the staff either did not administer the medication due to the resident being out of parameters but still signed the MAR as if it had been given, or in one case, administered the medication despite the resident being out of parameters, after which the resident spit out the medication. The MAs did not consistently notify a nurse when the medication was held or refused, and documentation on the MAR did not accurately reflect the events. The staff cited reasons such as being rushed, forgetting to document, or assuming standard parameters, and acknowledged that their actions did not align with facility policy or physician orders. The Director of Nursing (DON) confirmed that the staff did not follow the required procedures for checking parameters, documenting accurately, and notifying nursing staff when medications were held or refused. The DON also verified that all three staff members had received training and competency assessments related to medication administration, including following parameters and proper documentation. However, the failure to adhere to these protocols resulted in inaccurate MAR documentation and a lack of appropriate communication regarding the resident's medication administration.
Inaccurate Medication Administration Documentation and Failure to Follow Parameters
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, specifically regarding the administration of a physician-ordered antihypertensive medication. The resident, an older female with diagnoses including acute kidney failure, secondary malignant neoplasms, and hypertension, had a physician's order for Cozaar (Losartan Potassium) with specific parameters to hold the medication if systolic blood pressure was below 120 or diastolic below 60, or if pulse was below 60. On three consecutive days, medication administration records (MAR) were signed off by medication aides as if the medication had been administered, despite the resident's blood pressure readings being outside the prescribed parameters for safe administration. Interviews with the medication aides responsible for those days revealed that two of them did not administer the medication because the resident's blood pressure was out of range, but they erroneously documented it as given on the MAR. The third aide administered the medication despite the blood pressure being out of parameters, and the resident subsequently spit out the medication due to nausea. This aide also documented the medication as administered and did not make a note about the incident or notify a nurse. All three aides failed to notify nursing staff when the medication was held or refused, as required by facility policy and physician orders. The Director of Nursing confirmed that the medication should not have been administered on any of the three days based on the resident's blood pressure readings and that the documentation on the MAR was inaccurate. The facility's policy required staff to check vital signs, hold medication if parameters were not met, and accurately document administration or refusal, including notifying the nurse when medication was held or refused. Despite prior training and competency assessments, the staff did not follow these procedures, resulting in incomplete and inaccurate clinical records for the resident.
Failure to Update Care Plan After Code Status Change
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan for a resident was not revised after the resident's code status was changed from Do Not Resuscitate (DNR) to Full Code. This oversight was identified during a review of the resident's records, which showed that the care plan still reflected a DNR status despite the physician orders indicating a Full Code status. The MDS Coordinator acknowledged that the care plan should have been updated to reflect the resident's current code status. The Director of Nursing (DON) confirmed that the care plan should have been updated when the change in code status occurred. The resident had previously been on hospice services with a DNR status, but after returning from the hospital, the resident and family requested a change to Full Code. The facility's policy on care plan revision upon status change outlines the procedure for updating care plans, which includes collaboration among the MDS Coordinator and the Interdisciplinary Team, documentation of discussions, and communication of care plan interventions to all staff involved in the resident's care. However, the care plan for this resident was missed, leading to a discrepancy between the care plan and the resident's current needs.
Failure to Maintain Respiratory Care Supplies
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in the maintenance and replacement of suction and oxygen supplies. The resident, a male with severe cognitive impairment and multiple diagnoses including COPD and congestive heart failure, required respiratory care as part of his comprehensive care plan. However, observations revealed that the suction canister, tubing, and Yankauer suction device in the resident's room were not dated or changed as per the facility's protocol, with the Yankauer device still in packaging dated over a week prior. Interviews with facility staff, including a registered nurse (RN), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that the supplies were supposed to be changed weekly or as needed if soiled. The RN admitted that the supplies should have been changed and acknowledged the risk of infection if they were not. The ADON expressed doubt about the accuracy of the dates on the supplies and noted that the respiratory therapist had not been present for several days. The DON reiterated the importance of changing disposable supplies to prevent infection. The facility's Infection Prevention and Control Program Policy outlined the requirement for single-use disposable equipment to be discarded after use and for sterile supplies to be inspected before use. Despite these policies, the facility did not have a physician order for changing the suction and oxygen supplies, which could lead to bacterial growth and infection. The lack of adherence to these protocols and the absence of a physician order for changing supplies contributed to the deficiency in providing safe respiratory care for the resident.
Deficiency in Hand Hygiene Observed in Kitchen Staff
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene, as observed with Cook E. During a kitchen tour, Cook E was seen washing her hands for only 5 seconds after picking up an item from the floor and for 3 seconds after taking food temperatures. This was contrary to the facility's policy and professional standards, which require handwashing for at least 20 seconds to prevent cross-contamination and the spread of infections. Interviews with Cook E and other staff members, including the Dietary Manager (DM), Assistant Director of Nursing (ADON), and Director of Nursing (DON), confirmed the importance of proper hand hygiene. Cook E acknowledged the requirement for 20-second handwashing but admitted to not following it due to nervousness. The facility's hand hygiene policy, dated 10/24/22, mandates thorough handwashing to prevent infection spread, aligning with FDA Food Code 2022 standards. Despite regular in-service training, the deficiency in hand hygiene was evident, posing a risk of cross-contamination and infection to residents.
Inaccurate Documentation of Oxygen Therapy
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the administration of supplemental oxygen. The resident, an elderly female with dementia and diastolic heart failure, had an active order for oxygen therapy as needed for hypoxia. However, the treatment administration record did not reflect the administration of oxygen during August and September, despite observations of the resident receiving oxygen on multiple occasions. Interviews with staff, including the MDS coordinator, LVN, ADON, and DON, confirmed discrepancies between the observed administration of oxygen and the documentation in the medical records. The MDS assessment inaccurately indicated that the resident had not received oxygen therapy in the past 14 days, contradicting the observations and staff statements. The LVN and ADON acknowledged the importance of documenting PRN treatments in the MAR to prevent errors and ensure accurate records for future treatment decisions. The DON also emphasized the need for accurate documentation to reflect the resident's actual use of oxygen. Despite requests, the facility did not provide a policy for medication administration, highlighting a gap in procedural adherence.
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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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