Estates Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 201 Sycamore School Rd, Fort Worth, Texas 76134
- CMS Provider Number
- 675028
- Inspections on file
- 61
- Latest survey
- May 1, 2026
- Citations (last 12 mo.)
- 29 (3 serious)
Citation history
Health deficiencies cited at Estates Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Abuse During Incontinent Care: A CNA was observed on video using forceful and aggressive handling while providing incontinent care to a resident with severe cognitive impairment and total ADL dependence. The resident yelled, moaned, and repeatedly asked what he had done while the CNA grabbed his wrists, turned him forcefully, held him down, and moved his limbs without speaking. Later, the resident told staff and family that a tall man had entered his room, held him down, and hit him, and the CNA admitted he had gotten rough and restrained the resident during care.
A facility failed to provide private space for resident council meetings, which were held in the dining room for 15 of 15 confidential residents reviewed. During a meeting with 12 residents, staff entered the room despite do-not-enter signs posted on both doors, and residents said interruptions were frequent and made them feel unable to speak freely. The Activity Director and Administrator both stated the meetings were expected to remain private, and the facility policy stated the resident council would be provided private space.
Unsupervised smoking occurred when three residents who were assessed as needing direct supervision were observed smoking on the patio without staff present. One resident with heart disease, HF, HTN, depression, and moderate cognitive impairment smoked alone, while two other residents with dementia, schizophrenia, anxiety, COPD, and a stroke history shared a cigarette and had cigarettes and a lighter on hand. Staff later stated the residents should not have been smoking unsupervised, and the facility policy required direct view supervision and no ignition sources kept by residents.
Failure to care plan a resident's face-picking behavior. A resident with MS, chronic pulmonary edema, lymphedema, HTN, and non-Alzheimer's dementia had moderate cognitive impairment and developed recurring red, scabbed areas on her face from picking at the skin. Staff observed the behavior, applied ointment, and tried to redirect and educate her, but the behavior was not included in the care plan even though nursing, MDS, DON, and ADON all acknowledged it should have been.
Incorrect G-tube Flush Volume During Enteral Feeding: A resident with severe cognitive impairment, aphasia, stroke, hemiplegia, and a feeding tube was observed receiving enteral feeding when an RN flushed the G-tube with 30 ml of water before and after the feeding instead of the ordered 60 ml. The RN stated he read the order wrong, and the DON and ADON confirmed the correct flush amount should have been followed.
Unlocked Medication Cart Left Accessible: A medication cart outside the nurses' station was found unlocked with multiple Rx and OTC meds in the drawers while an LVN briefly walked away from it. The LVN stated she knew the cart should have been locked, and the DON and other nursing staff stated carts must be locked any time staff are not directly in control of them. The facility policy stated meds and biologicals must be stored safely and securely and be accessible only to authorized personnel.
A resident’s urine measuring cylinder was left on her bedside table with clean items such as a water cup, hairbrush, and book. The resident said this had happened before after her urinary catheter bag was emptied, and staff interviews confirmed the cylinder should not have been kept on the clean bedside table because of cross contamination concerns and the possibility that a confused resident might try to drink from it.
A resident with multiple chronic conditions, including dementia, Parkinson’s disease, cirrhosis, and psychiatric diagnoses, experienced a documented 15.9% weight loss over one month, dropping from approximately 145 lbs to 122 lbs. Despite facility policy requiring monthly weights, re-weighs within 24 hours for significant changes, and immediate notification of the MD, RD, and family for >5% weight loss, the March weight was not promptly entered into the EHR, no re-weigh was documented, and no new dietary orders or nutrition-focused care plan interventions were initiated. The DON acknowledged missing the entry of the weight, which prevented automated alerts and review, while the MD and RD both stated they expected to be notified of such a change. Staff interviews indicated the resident had a good appetite and ate most meals, but the facility failed to recognize and act on the significant documented weight loss in accordance with its policies.
A resident with multiple chronic conditions, including dementia, Parkinson’s disease, cirrhosis, and psychiatric diagnoses, experienced a significant unaddressed weight loss over several months. EHR vitals showed a drop from the mid-140 lb range to just over 120 lbs, but the annual MDS documented no or unknown weight loss and the care plan contained no nutrition or weight-loss focus. The MDS nurse relied on incomplete weight data because current weights were not promptly entered into the system, and no alert for weight loss was generated. The DON reported that weights were first recorded on paper by the Activity Director and later entered into the electronic system, but the resident’s most recent weight was not entered before weekly review or the annual MDS, so the weight loss did not trigger review or care planning, resulting in an inaccurate assessment.
A resident with moderate cognitive impairment and multiple complex diagnoses experienced a significant, documented weight loss over several weeks, but the facility failed to develop a comprehensive care plan addressing nutrition and weight loss. The resident’s care plan focused on dental issues and contained no nutrition or weight-loss interventions, and the Annual MDS documented no or unknown weight loss. Weights were taken and recorded on paper by the Activity Director, but the DON did not enter the most recent weight into the electronic system by the facility’s required timeframe, preventing automated triggers for weight loss and review during weekly meetings. The MDS nurse, relying on incomplete electronic weight data and system alerts, did not identify the weight loss, resulting in the absence of appropriate care plan goals and interventions for the resident’s significant weight change.
A resident with diabetes, bilateral above-knee amputations, heart failure, and a history of constipation went several days without a documented BM despite a PRN order for bisacodyl suppositories to be used if no BM occurred within 48 hours. The MAR showed the suppository was given only twice during this period, and the resident later reported abdominal discomfort and believed his last BM had been the previous week. An RN, unaware of the prolonged absence of a BM, contacted the physician only after the resident requested an enema, then administered a suppository per the physician’s direction, resulting in a large BM. CNAs reported they documented BMs on flowsheets but did not routinely review bowel patterns, assuming the nurse would be notified electronically, while the DON stated the system should alert nurses after two days without a BM and acknowledged there was no specific constipation policy.
A resident with multiple chronic conditions, including dementia, Parkinson’s disease, cirrhosis, and psychiatric disorders, experienced a documented 15.9% weight loss over one month, but staff did not recognize or act on this change. Monthly weights were obtained and written on paper by the Activity Director, but the DON did not timely enter the most recent weight into the EHR, preventing automated alerts and review. The resident’s MDS inaccurately reflected no weight loss, the care plan lacked any nutrition or weight-loss focus, no re-weigh was documented, and no MD or RD notification or dietary interventions were initiated despite facility policy defining significant weight loss and outlining required actions. Interviews with the MD, RD, CNA, DON, Compliance Nurse, and Activity Director confirmed that the expected processes for monitoring and responding to significant weight changes were not followed for this resident.
Staff failed to keep a clean linen cart covered and left a sealed red biohazard bag unattended in a hallway after wound care. Multiple staff members acknowledged responsibility for maintaining sanitary conditions, but did not follow infection control protocols as outlined in facility policy. These lapses resulted in exposed linen and improper handling of potentially infectious materials.
Two residents with documented mood and behavioral issues, including anxiety, refusal of care, and mental health diagnoses, were not accurately coded for these conditions in their MDS assessments. Despite care plans, physician notes, and staff interviews confirming ongoing behavioral and mood disturbances, the MDS assessments failed to reflect these issues, resulting in inaccurate documentation of their status.
Two residents requiring respiratory support did not have their nasal cannula tubing and CPAP mask properly stored in clean, dated plastic bags when not in use, as required by facility policy and professional standards. Staff interviews confirmed the expectation for proper storage, but the equipment was found unbagged or inappropriately stored, and staff failed to notice or address the issue.
Staff failed to follow proper infection control procedures for three residents, including improper use of PPE, inadequate hand hygiene, and cross-contamination during wound care. Housekeeping and nursing staff demonstrated lack of awareness and training regarding enhanced barrier precautions and cleaning protocols for fungal infections.
A resident with chronic kidney disease and multiple comorbidities missed three consecutive dialysis sessions, and facility staff failed to document all missed treatments, review critical lab results promptly, or ensure appropriate monitoring and intervention. Despite the resident's ongoing refusals, there was inadequate follow-up and communication with the dialysis center, and the care plan was not updated until after surveyor involvement.
Multiple residents experienced abuse due to inadequate supervision and staff misconduct. Two residents with dementia engaged in a prolonged physical altercation in a memory care unit while the assigned nurse was in the office and failed to intervene promptly, resulting in injuries. In a separate event, a CNA verbally abused a resident during an exchange, causing emotional distress. These incidents demonstrate lapses in supervision and staff conduct, leading to resident harm.
Two residents with dementia and a history of behavioral risks were left unsupervised in a common area, leading to a physical altercation in which one resident was punched multiple times and sustained facial injuries. The assigned RN was in the office with the door closed and did not have visual access to the residents, resulting in a delayed response and failure to prevent or promptly intervene in the incident.
Two residents with PASRR positive status did not have their specialized services documentation submitted within the required timeframe after interdisciplinary team meetings. Both residents had complex medical and mental health needs, and while services were reportedly provided, required forms were delayed due to technical issues with the documentation portal and internal communication lapses. The Director of Rehabilitation was responsible for timely submission but encountered system glitches and backlogs, resulting in noncompliance with facility policy.
A resident with chronic medical conditions and no cognitive impairment reported to an LVN that a CNA used profanity towards him, causing distress. The LVN reassigned the CNA but did not immediately notify the Administrator as required by policy. The incident was only reported to the Administrator and DON the following day after the resident informed the Social Worker, resulting in a delay in investigation and intervention.
Three residents experienced abuse, including a case where a CNA antagonized and physically contacted a resident with severe cognitive impairment, and another incident where two residents engaged in a verbal and physical altercation after one verbally abused the other. Both incidents involved failures to prevent emotional, mental, and physical abuse, with affected residents at risk of psychological harm.
A resident with a high fall risk and double amputation sustained a head injury after his wheelchair's anti-tippers were removed during dialysis at his request, and staff failed to ensure their reapplication before transport. The resident attempted to board the facility van independently, against the van driver's instructions, and fell backwards when his wheelchair tipped on the lift, resulting in abrasions to his head and elbow.
Two residents did not receive pharmaceutical services that ensured accurate dispensing and administration of PRN pain medications. One resident with a recent opioid overdose was given hydrocodone/acetaminophen against hospital discharge instructions, and documentation was incomplete or inconsistent. For another resident, there were discrepancies between the narcotic log and the MAR, with staff failing to document PRN medication administration as required by facility policy. Staff interviews confirmed these documentation lapses and failure to follow physician orders.
Two residents in a facility experienced significant safety failures. One resident with cognitive impairment eloped from a secure unit by prying open a window and was found 0.9 miles away, carrying potentially dangerous items. Another resident, who was paraplegic, was not properly secured in a transport van, resulting in a fall and head injury. Both incidents were due to inadequate supervision and safety measures, highlighting deficiencies in the facility's care protocols.
A resident with pressure ulcers and a malfunctioning wound vacuum reported feeling unwell, but RN C delayed care for nearly 10 hours, failing to assess or address the resident's condition in a timely manner. The facility did not follow policies for notifying physicians or ensuring timely wound care, leading to a deficiency in care.
A resident with a history of pressure ulcers did not receive timely wound care after reporting a leaking wound vac to RN C. The resident experienced discomfort and drainage due to a 10-hour delay in care, as RN C did not have enough supplies and failed to prioritize the resident's needs. Interviews revealed ongoing issues with staff training and communication regarding wound care procedures.
The facility failed to ensure proper dialysis communication for two residents with end-stage renal disease, missing multiple communication forms from the dialysis center. This deficiency involved not receiving or documenting necessary information, despite the residents attending regular dialysis sessions. Staff interviews revealed a lack of adherence to the facility's dialysis policy, highlighting the importance of these forms for continuity of care.
The facility failed to provide adequate pharmaceutical services, with discrepancies in narcotic logs and expired medications on a medication cart. A nurse was observed mishandling medications, including not documenting narcotic administration and failing to destroy unused medication. Interviews revealed that facility policies were not followed, contributing to these deficiencies.
A resident with multiple medical conditions, including pressure ulcers, reported feeling unwell and having issues with his wound vacuum to RN C. Despite the resident's pale appearance and complaints, RN C delayed addressing his needs and failed to notify the physician or DON. The resident's condition was not reassessed, and the physician was not informed, leading to a deficiency in care.
A resident with severe cognitive impairment and malnutrition risk did not receive a speech therapy evaluation as ordered by a physician. The facility's communication breakdown led to the speech therapist not being informed of the order, and the DON was unaware of the dietician's recommendation. The lack of a facility policy on following physician orders contributed to this oversight.
A resident fell in a van due to improper wheelchair strapping, resulting in a head injury and hospital visit. The facility failed to report the incident to the State Survey Agency, as the Administrator believed the transport company would handle it. The resident, with a history of paraplegia and other conditions, was at risk for falls, and the incident was not reported within the required timeframe.
A resident with paraplegia fell in a transport van due to improper wheelchair securing, resulting in a head injury. The facility failed to investigate or report the incident to the state agency, as the Administrator believed the transport company was responsible. This inaction placed the resident at risk of further harm.
The facility failed to ensure proper labeling and secure storage of insulin vials on a medication cart. An observation revealed an opened Humalog vial without an open date and a Levemir vial with an incorrect date. Interviews with RN C, the ADON, and the DON highlighted a lack of adherence to the facility's policy on dating insulin vials, with no recent training documentation provided.
A resident with multiple health conditions and moderate cognitive impairment fell and fractured her femur during a bed bath when a CNA failed to obtain the required assistance from another staff member. Despite the resident's care plan indicating the need for two staff members due to her bariatric status, the CNA proceeded alone, leading to the accident.
A resident with multiple health issues, including chronic kidney disease and urine retention, did not have a comprehensive care plan implemented to monitor signs of dehydration. Despite the care plan identifying potential fluid deficit, there was no evidence of monitoring in the resident's records. Observations showed no urine output in the catheter bag, and staff interviews revealed inconsistencies in monitoring and documentation. The facility's policy required a comprehensive care plan, but it was not effectively implemented, placing the resident at risk.
A resident with an indwelling urinary catheter was not properly monitored for urine output and signs of dehydration, despite having a care plan indicating the need for such monitoring. Observations showed no urine output in the catheter bag, and staff interviews revealed inconsistencies in monitoring and documentation. The facility's policy required comprehensive care plans, but the lack of adherence led to a deficiency in care.
The facility failed to secure a medication cart on Hall 200, leaving it unlocked and unattended on two occasions. LVNs involved acknowledged the risk and the requirement to lock the cart, as per the facility's policy. The DON and Administrator confirmed staff responsibility for securing the cart.
A resident's call light was not within reach, as it was placed on the other side of a privacy curtain over a vacant bed's headboard. The resident, who required assistance for daily activities and had a recent fall, was unable to locate the call light. Staff, including the DON and CNAs, were unaware of the issue, although they acknowledged the importance of accessible call lights for resident safety. The facility's policy on resident rights was not upheld in this instance.
A resident with a history of falls and severe cognitive impairment fell from her bed, sustaining a bruise on her forehead, due to the facility's failure to place fall mats on both sides of her bed. The care plan did not initially include fall mats as an intervention, and staff acknowledged the oversight. The facility's Fall Risk Assessment policy was not adequately followed, leading to the resident's fall and injury.
A resident with severe cognitive impairment suffered a burn blister on her wrist after spilling hot coffee on herself in the dining room. The incident occurred because the resident, who wore gloves to prevent skin scratching, lost grip of the cup. Despite the facility's care plan to prevent burns, the interventions were not effectively implemented, leading to the injury.
The facility failed to ensure disposable razors were kept out of reach in a shower room, posing a risk of injury to residents. Razors were found on top of a sharps container, accessible to residents, contrary to the facility's policy requiring proper storage. Staff interviews confirmed the risk of harm if razors were not disposed of correctly.
The facility did not have a full-time Director of Nursing (DON) for 53 out of 65 days, as the responsibilities were divided among the ADON, MDS Coordinator, and Regional Compliance Nurse. The Administrator acknowledged the absence of a dedicated DON and the lack of a policy for DON coverage.
Abuse During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a CNA used forceful and aggressive handling during incontinent care. The resident was a male with severe cognitive impairment, including a BIMS score of 0, and diagnoses that included heart failure, hypertension, end stage renal disease, Alzheimer's disease, stroke, and non-Alzheimer's dementia. He was dependent for ADLs and required assistance from one staff member for care. During the early morning care episode, video footage showed the CNA entering the resident's room, turning on the light, removing the covers, and then grabbing the resident's wrists and forcefully turning him onto his side while removing the brief. The CNA placed his weight on the resident's shoulder, then later pushed the resident to the opposite side, grabbed the resident's wrist again, and forcefully yanked him over while the resident yelled and moaned in distress. The footage also showed the CNA crossing the resident's wrists over his chest, holding him down while adjusting the brief, and grabbing the resident's ankles and moving them toward the center of the bed. Throughout the incident, the CNA did not speak to the resident, and the resident repeatedly asked what he had done. Later that morning, the resident told staff and family that a tall man had entered his room during the night, held him down, and hit him on the face. He said he felt fearful and did not want that man in his room again. Staff who interviewed the resident reported that his account remained consistent, and multiple staff stated the resident had not been combative during care and had not previously made similar allegations. The CNA acknowledged that he had gotten rough with the resident, restrained him while putting on the brief, and admitted he probably should have stopped when the resident was yelling and asking him to stop.
Resident Council Meetings Lacked Privacy
Penalty
Summary
The facility failed to provide a private meeting space for resident council meetings for 15 of 15 confidential residents reviewed for resident council. Observation and interview on 04/29/26 at 9:30 AM during a confidential resident group meeting with 12 residents revealed that the resident council meetings were held once a month in the dining room. The dining room had two entrances, both doors were closed, and the Activity Director posted do not enter signs on each door, but three staff members still entered the dining room during the meeting. Residents stated that interruptions during resident council meetings were frequent and that they felt like they could not speak freely because of staff interruptions. On 04/30/26 at 6:25 PM, the Activity Director stated staff interrupted the meetings by entering or attempting to enter the dining room and that she would ask staff to leave. On 05/01/26 at 8:22 AM, the Administrator stated staff were expected to respect residents' privacy during resident council meetings so residents could express concerns without feeling intimidated. The facility policy titled Resident Council, revised 12/2016, stated that the facility would provide the resident council with private space.
Unsupervised Smoking by Residents With Direct-Supervision Requirements
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision during smoking activities for three residents who were supposed to be directly supervised while smoking. Resident #7, a male with heart disease, heart failure, hypertension, depression, and a BIMS score of 11, had a smoking assessment stating he was safe to smoke but required direct supervision and that smoking materials were to be kept at the nurse station. Resident #23, a female with non-Alzheimer's dementia, anxiety disorder, schizophrenia, and a BIMS score of 9, had a care plan noting she smoked and was sometimes non-compliant with smoking policy, with interventions to monitor her as needed and re-educate her on smoking policy; her smoking assessment also required direct supervision. Resident #97, a male with lumbar vertebra fracture, anxiety disorder, COPD, and cerebral infarction, also had a smoking assessment stating he was safe to smoke and required direct supervision, with smoking materials kept at the nurse station. During observation, the three residents were seen smoking on the patio with no staff present. Resident #97 was sharing a cigarette with Resident #23, while Resident #7 was smoking alone at another table. Resident #7 stated he had found an extra cigarette in his walker bag and that Resident #97 had let him borrow the lighter. When CNA Y arrived with the smoking paraphernalia in a lock box, she stated the residents should not have been smoking unsupervised and did not know where they had gotten their cigarettes and lighter. Resident #97 then tucked four cigarettes and a lighter under his leg. Interviews with the DON, ADON J, and the Administrator confirmed residents were not allowed to smoke unsupervised or keep cigarettes or lighters on them, and the facility's smoking policy required residents to be within direct view of the smoking supervisor and in close proximity for quick response in an emergency.
Failure to Care Plan Face-Picking Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #10 that addressed her behavior of picking at her face. Resident #10 was admitted with diagnoses including multiple sclerosis, chronic pulmonary edema, lymphedema, essential hypertension, and Non-Alzheimer's Dementia, and her BIMS score was 10, indicating moderate cognitive impairment. Her admission MDS assessment was dated 02/11/26, and the care plan dated 02/13/26 did not address the face-picking behavior that was causing redness and skin-breakdown. During observation on 04/28/26, Resident #10 was seen sitting in her wheelchair in her room with small red areas on her face. She stated staff told her the red areas were caused by scratching herself, and she said she washes her face every day and picks at the areas because the scabbing itches. She also stated staff put ointment on the red spots. CNA N stated the skin-breakdown around the resident's face had been present for a while, that the red spots would heal and scab but then the scabs would come off, and that it appeared the resident picked at the scabs. Interviews with nursing and management staff confirmed the behavior was known but not care planned. LVN O stated the resident had a tendency to pick on her face, causing skin-breakdown, and that staff tried to redirect and educate her not to pick at her skin. The MDS Coordinator stated behaviors should be addressed in the care plan and reviewed the resident's care plan, confirming the behavior was not included. The Treatment Nurse, DON, and ADON also stated the resident's face-picking behavior should have been care planned and acknowledged it was missed.
Incorrect G-tube Flush Volume During Enteral Feeding
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident who was fed by enteral means. Resident #11, a [AGE]-year-old female with diagnoses including aphasia, stroke, hemiplegia, and cerebral infarction, had a BIMS score of 0 and was on a feeding tube due to impaired swallowing. Her care plan directed staff to follow the current feeding orders, and the order summary included instructions to flush the enteral tube with 60 ml of water before and after feedings, along with separate flush instructions for medication administration. During observation of a feeding, RN D checked g-tube placement, poured 30 ml of water into the syringe and let it flow by gravity, then poured formula into the syringe and flushed with 30 ml of water after the feeding. During interview, RN D stated he had read the flush order wrong and said the order was 60 ml. The DON stated that if the order was 60 ml, it should have been followed, and ADON J stated the correct flush before and after feedings should be 60 ml. The facility policy stated that enteral formulas and medications are to be administered safely and effectively based on nursing assessment and physician consultation.
Unlocked Medication Cart Left Accessible
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and that only authorized personnel had access to medication cart keys for 1 of 5 carts reviewed. On 04/28/26 at 5:30 a.m., a medication cart located outside the only nurses' station was observed unlocked, with all drawers able to be opened and multiple prescription and over-the-counter medications inside the drawers. LVN-A stated in an interview at 5:33 a.m. that she had walked away from the cart for just a minute to talk with someone and knew the cart should have been locked before leaving it, but did not think she would be gone very long. During interviews on 04/30/26, the DON stated all medication carts were required to be locked whenever the nurse or medication aide was not directly in control of the cart. RN-B, LVN-C, RN-D, MA-E, and MA-F each stated that their carts had to be locked any time they were not directly at them. The facility policy, Medication Storage in the Facility, dated 2025, stated that medications and biologicals are stored safely, securely, and properly, and that the medication supply is accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
Infection Control Lapse With Urine Measuring Cylinder Left on Bedside Table
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident reviewed for infection control. Staff left a graduated cylinder used to measure urine output on the resident’s bedside table, where the resident also had her water cup, hairbrush, and book. The cylinder had traces of yellow liquid at the bottom, and the resident stated it had been left there after the night shift emptied her urinary catheter collection bag around 6:00 a.m. She also stated this had happened before and that she had asked CNAs not to place it there, but they continued to forget. During interviews, the DON stated the graduated cylinder should not have been left on the bedside table because the table was considered clean and the cylinder was not clean. She stated this could cause cross contamination with the resident’s food and drink, and that a confused resident might try to drink from it. Multiple staff members, including a CNA, RN, LVN, and other CNAs, stated the cylinder used to empty urine bags should not be left on a bedside table with clean items and should be kept separate because of cross contamination concerns.
Failure to Notify Physician and Address Significant Resident Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician when there was a significant change in the resident’s nutritional status, specifically a substantial weight loss. The resident was an older male with multiple active diagnoses, including non-Alzheimer’s dementia, Parkinson’s disease, depression, schizophrenia, history of alcohol abuse, cirrhosis, metabolic encephalopathy, and a benign neoplasm of the sigmoid colon. His Annual MDS dated mid-March reflected a weight of 145 pounds and no or unknown weight loss, and his care plan included a focus on dental health problems but did not include a focus or interventions related to nutrition or weight loss. Laboratory results from early March showed a low glucose level of 68 and a slightly low albumin level of 3.3. Record review of the resident’s weights showed that he weighed 148.2 lbs in early January, 145.5 lbs in early February, and 122.4 lbs in early March, representing a 15.9% loss and a 23.1 lb decrease between early February and early March. There were no documented re-weighs after the March weight, and there were no physician orders addressing weight loss despite this significant change. The facility’s weekly resident review on March 12 did not list any triggers for weight loss in 30 days, and the resident was not reviewed. The DON later stated that she entered all weights into the electronic health record but had missed entering this resident’s March 9 weight, which prevented the system from triggering an alert for weight loss and from identifying the change during the weekly review and MDS update. Interviews with staff showed that CNAs and the Activity Director observed the resident to have a good appetite and to usually eat most or all of his food, and the resident himself reported that he felt well, did not feel he was losing weight, and felt he received enough food, including preferred cultural foods. The DON stated that a weight loss of over 5% should have been immediately reported to the MD, RD, and family, and acknowledged that missing significant weight loss could place residents at risk of untreated serious health conditions. The MD stated his expectation was to be notified of any weight change over 5% gain or loss and that he had not been informed of this resident’s significant weight loss. The RD stated that if a resident had more than 5% weight loss in one month, she would expect immediate notification and interventions such as re-weighs, fortified diet, supplements, and weekly weights. The facility’s written policies on notifying the physician of change in status and on resident weights required timely weighing, review of weights for significant changes, re-weighs within 24 hours, and notification of the physician and family for significant weight loss, but these procedures were not followed for this resident’s documented 15.9% weight loss. The DON further explained that the Activity Director was responsible for obtaining monthly weights and documenting them on paper, while the DON was responsible for entering them into the electronic system and reviewing them for significant changes. The facility did not keep a running log of weights on the paper document, and the Activity Director was not responsible for monitoring the numbers for significant changes. The DON stated that she was behind on documentation due to training and did not enter the resident’s March 9 weight until after the 15th of the month, which caused the weight loss to be missed during both the weekly resident review and the MDS assessment process. The Compliance Nurse stated that the expectation for significant weight loss was to re-weigh and notify the MD, RD, and family, and to update the care plan with interventions such as weekly weights and a nutrition risk program, but could not state whether the resident’s weight was accurate or why there was no documented re-weigh. Overall, the facility did not follow its own policies and did not immediately notify the physician or implement care plan interventions in response to the resident’s significant weight loss.
Inaccurate MDS Assessment Due to Missed Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment for a resident who experienced significant weight loss. The resident was an older male with multiple active diagnoses, including non-Alzheimer’s dementia, Parkinson’s disease, depression, schizophrenia, history of alcohol abuse, cirrhosis, metabolic encephalopathy, and a benign neoplasm of the sigmoid colon. His Annual MDS, dated 03/15/26, documented him as 66 inches tall and 145 pounds with no or unknown weight loss, despite electronic health record (EHR) vitals showing a substantial decrease in weight over the preceding months. Record review showed the resident’s weights as 148.2 lbs on 01/09/26, 145.5 lbs on 02/10/26, and 122.4 lbs on 03/09/26, with no documented re-weighs. A weights and vitals summary dated 03/24/26 reflected that the 03/09/26 weight of 122.4 lbs represented a 15.9% loss (23.1 lbs) from the 02/10/26 weight. The resident’s care plan, dated 05/14/25, contained a focus on dental health problems with related interventions but did not include a focus or interventions regarding nutrition or weight loss. A weekly resident review document from 03/12/26 showed there were no triggers for weight loss in 30 days and the resident was not reviewed. In interviews, the MDS nurse stated she had been in the role for about 11 months and that significant weight loss should trigger an alert in the system for MDS updating. She reported that when she completed the resident’s annual MDS on 03/15/26, there was no alert for weight loss and that current weights were not always entered into the system immediately, so she used the data available at the time. The DON stated that weekly meetings were held to review residents who triggered alerts for ADL declines, including weight loss, but the resident did not trigger because the 03/09/26 weight had not been entered. The DON acknowledged she was behind on documentation due to training and did not enter the 03/09/26 weight until after the 15th, causing the resident’s significant weight loss to be missed during both the weekly review and the MDS update, and resulting in an inaccurate MDS assessment and missed opportunity to identify the weight loss. The facility’s comprehensive care planning policy required use of the MDS to identify needs and revise care plans after each MDS assessment, but this process did not occur for the resident’s weight loss because the data were not timely entered and did not trigger further assessment or care planning.
Failure to Care Plan for Significant Weight Loss Due to Delayed Weight Entry and Inaccurate MDS Data
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s significant weight loss. The resident was an older male with moderate cognitive impairment (BIMS score of 9) and multiple active diagnoses, including non-Alzheimer’s dementia, Parkinson’s disease, depression, schizophrenia, history of alcohol abuse, cirrhosis, metabolic encephalopathy, and a benign neoplasm of the sigmoid colon. His Annual MDS assessment dated 03/15/26 documented no or unknown weight loss, and his care plan dated 05/14/25 included a problem focus on dental health but did not include any focus, goals, or interventions related to nutrition or weight loss. Record review showed that the resident’s weight declined from 148.2 lbs on 01/09/26 to 145.5 lbs on 02/10/26, and then to 122.4 lbs on 03/09/26, representing a documented 15.9% loss and 23.1 lbs lost between 02/10/26 and 03/09/26. There were no documented re-weighs after the 03/09/26 weight. A weights and vitals summary dated 03/24/26 reflected the 03/09/26 weight of 122.4 lbs with a noted percentage change, but this information was not incorporated into the MDS or care plan at the time of the Annual MDS assessment. The facility’s weekly resident review on 03/12/26 contained no triggers for weight loss in 30 days, and the resident was not reviewed for weight loss. Interviews revealed that the MDS nurse relied on system alerts and available weight data when completing MDS assessments and stated that significant weight loss should trigger an alert and lead to updated assessments and care plan interventions. She reported that no alert appeared for this resident’s weight loss because current weights were not always entered into the system in a timely manner, and she used the data that were available, which did not reflect the significant loss. The DON stated that she was responsible for entering weights from paper records into the electronic system and acknowledged that the resident’s 03/09/26 weight was not entered by the time of the weekly review or the subsequent QAPI meeting, due to being behind on documentation. The DON also stated that the Activity Director took and recorded weights on paper without a running log, and that the facility’s policy required weights and documentation to be completed by the 10th of each month. As a result of these delays and omissions, the resident’s significant weight loss was not identified in the MDS, did not trigger review, and was not addressed in a comprehensive care plan as required by the facility’s Comprehensive Care Planning policy.
Failure to Treat Resident Constipation per Physician Orders and Bowel Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care for constipation as ordered by the physician and in accordance with the resident’s comprehensive assessment and care needs. A cognitively intact male resident with diabetes, bilateral above-knee amputations, heart failure, and constipation had an admission MDS showing he required partial assistance with toileting and a care plan noting self-care deficit and fall risk. The bowel continence flow sheet showed no bowel movement documented for this resident from 03/17/26 through 03/24/26, despite an existing PRN order dated 03/14/26 for a Dulcolax (bisacodyl) 10 mg rectal suppository every 12 hours as needed for constipation if no bowel movement occurred in 48 hours. The MAR reflected the suppository was administered only on 03/14/26 and again on 03/24/26, indicating the order was not used to address the multi-day absence of bowel movements. On 03/24/26 in the morning, the resident reported needing something for constipation, described abdominal discomfort, and believed his last bowel movement had been the previous week. He requested an enema from an RN, who stated he would need to contact the physician because there was only an order for a suppository. The RN contacted the physician, who instructed him to administer the suppository first and call back if there were no results; the RN then administered the suppository around 11:15 AM, after which the resident had a large bowel movement. The RN stated he was unaware the resident had not had a bowel movement since the prior week and indicated CNAs were responsible for documenting bowel movements and notifying the nurse if there was no bowel movement for more than two days. A CNA reported the resident had not complained to her about not having a bowel movement and that CNAs typically did not review bowel patterns in the Kardex, believing the nurse was notified by the computer. The DON stated residents should not go more than three days without a bowel movement and that the system was designed to alert nurses if no bowel movement was documented in two days, but she did not know whether the alert was missed or failed to activate, and also stated there was no specific facility policy addressing constipation.
Failure to Identify and Address Significant Weight Loss and Nutritional Status
Penalty
Summary
The deficiency involves the facility’s failure to recognize, evaluate, and address a resident’s significant weight loss and nutritional status. The resident was an older male with multiple active diagnoses, including non-Alzheimer’s dementia, Parkinson’s disease, depression, schizophrenia, history of alcohol abuse, cirrhosis, metabolic encephalopathy, and a benign neoplasm of the sigmoid colon. His Annual MDS, dated 03/15/26, documented a weight of 145 pounds and indicated no or unknown weight loss, and his care plan contained a focus on dental health problems but no focus or interventions related to nutrition or weight loss. The resident’s diet order was for a regular diet with mechanical soft texture and regular consistency, and there were no physician orders addressing weight loss. Weight records in the EHR showed that the resident weighed 148.2 lbs on 01/09/26, 145.5 lbs on 02/10/26, and 122.4 lbs on 03/09/26, reflecting a documented 15.9% loss between 02/10/26 and 03/09/26. There were no documented re-weighs within 24 hours as required by facility policy, and the facility’s weekly resident review on 03/12/26 showed no triggers for weight loss in 30 days, so the resident was not reviewed. Lab work from 03/02/26 showed a low glucose of 68 and a slightly low albumin of 3.3, but there was no documentation that these findings were linked to an evaluation of his nutritional status or weight loss. The DON later acknowledged that she had not entered the 03/09/26 weight into the electronic record in a timely manner, which resulted in the resident not triggering for review and the MDS assessment remaining inaccurate regarding weight loss. Staff interviews and observations further demonstrated that the significant weight loss was not recognized or acted upon. The CNA reported that the resident usually ate all his food, preferred outside food, and appeared to have lost a little weight, which she stated nurses were aware of, but there was no documentation of follow-up. The DON stated that the resident did not appear physically smaller, that no nurses had reported concerns, and that she must have missed the resident’s weight loss when entering weights into the system. The Activity Director, who was responsible for obtaining monthly weights and had weighed the resident on 02/10/26 and 03/09/26 using the mechanical lift scale, stated she wrote the weights on paper and gave them to the DON, was not responsible for entering them into the EHR, and had not noticed any physical changes in the resident’s weight. The facility’s written policy required monthly weights by the 10th, review of all weights by the DON or designee, re-weighs within 24 hours when indicated, and specific actions for significant weight changes, but these procedures were not carried out for this resident, resulting in the failure to maintain acceptable parameters of nutritional status and to address a documented significant weight loss. Additional interviews with the MD, RD, Compliance Nurse, and other staff confirmed that the expected process for significant weight loss—re-weighing, notifying the MD, RD, and family, updating the care plan, and implementing interventions such as fortified diets, supplements, and weekly weights—was not initiated because the weight loss was not identified through the facility’s monitoring systems. The MD stated he expected notification for weight changes over 5% and consultation with the RD, but he was not informed of the resident’s significant weight loss. The RD stated she would expect immediate notification for more than 5% weight loss in one month and would advise re-weighs and nutritional interventions, but she reported that the resident’s weight had been considered stable and that she had no recollection of weight concerns. The Compliance Nurse described the facility’s expectations for managing significant weight loss, including re-weighs, notifications, care plan updates, and staff in-servicing, but could not confirm the accuracy of the resident’s weight or explain the lack of a documented re-weigh. Overall, the facility did not follow its own weight monitoring policy or implement appropriate assessment and care planning in response to the resident’s documented 15.9% weight loss.
Failure to Maintain Infection Control: Uncovered Linen Cart and Improper Biohazard Disposal
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by two specific incidents involving staff and environmental management. In one instance, a clean linen cart located in the 100 hall was observed with its cover left open, exposing the linen to potential environmental contamination. Multiple staff members, including an LVN, a CNA, and a medication aide, were present and acknowledged that the cart should have been covered when not in use to prevent contamination and unauthorized access. Staff interviews confirmed that it was the responsibility of all staff to ensure linen carts remained covered and sanitary. In a separate incident, a sealed red biohazard bag containing potentially infectious materials was found left on the floor in the hallway outside a resident's room in the 300 hall. Staff interviews revealed that the bag had been dropped by an LVN after wound care and was not immediately picked up or reported by another CNA who noticed it. The bag was eventually disposed of properly, but only after being left unattended in a public area, contrary to facility policy and infection control protocols. Both the LVN and CNA acknowledged the importance of immediate and proper disposal of biohazard materials to maintain a sanitary environment. Record review of the facility's Infection Control Policy and Procedure Manual confirmed that clean linen must be stored in a secured, covered cart and that biohazard materials must be properly labeled and disposed of immediately. The manual also specifies that all staff are responsible for maintaining sanitary conditions and preventing contamination. Interviews with the Administrator and DON further confirmed that these were the expected standards and that the observed lapses constituted a failure to follow established infection control procedures.
Failure to Accurately Code Mood and Behavior in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents regarding their mood and behavioral conditions. For one male resident with chronic respiratory failure, anxiety, and a history of refusing care and medications, the quarterly MDS assessment did not document any mood or behavioral issues, despite care plans and progress notes indicating frequent anxiety, refusal of care, false accusations, and attention-seeking behaviors. The resident's care plan specifically addressed behavioral problems and interventions, and physician notes documented ongoing behavioral concerns, yet these were not reflected in the MDS. A female resident with diagnoses including unspecified dementia, mood disorder, schizoaffective disorder, and major depressive disorder also had an MDS assessment that failed to document any mood or behavioral symptoms. Her care plan and physician orders indicated significant mental health issues, including risk for self-harm, aggression, and labile mood, with interventions in place to address these concerns. Observations and interviews with staff and family confirmed ongoing behavioral and mood disturbances, but these were not captured in the MDS assessment. Interviews with facility staff, including the MDS Coordinator, ADON, and DON, confirmed that the MDS assessments for both residents did not accurately reflect their mood and behavioral status. Staff acknowledged that these omissions could lead to inaccurate care planning and that the MDS Coordinator was responsible for ensuring assessment accuracy. The deficiency was identified through record reviews, staff interviews, and direct observation, revealing a failure to document and code mood and behavioral issues in the MDS for residents with clear histories and ongoing symptoms.
Improper Storage of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required respiratory support, as evidenced by improper storage of respiratory equipment. For one resident with diagnoses including heart failure, asthma, COPD, and respiratory failure, the nasal cannula and tubing were observed stored in a blue emesis bag attached to the concentrator, rather than in a clean, dated plastic bag as required to prevent environmental exposure and contamination. The resident reported using oxygen at night and was unsure when the tubing was last changed, indicating a lack of consistent adherence to proper storage and maintenance protocols. Another resident, admitted for short-term care with acute respiratory failure, shortness of breath, and obstructive sleep disorder, was observed with a CPAP mask left unbagged on the nightstand in his room. The resident stated he cleaned his own CPAP mask and tubing, but the tubing had not been bagged since his admission to the facility. Both residents were cognitively intact and had care plans and physician orders specifying the use of oxygen therapy or CPAP/BiPAP, with instructions for staff to monitor and store equipment appropriately. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed that the expectation was for all respiratory equipment such as nasal cannulas and CPAP/BiPAP masks to be stored in clean, dated plastic bags when not in use. Staff acknowledged responsibility for ensuring proper storage and monitoring of respiratory equipment, but failed to notice or correct the improper storage for these residents. The facility's oxygen administration policy also required changing or cleaning equipment when contaminated, but this was not followed in these instances.
Failure to Maintain Effective Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices for three residents. For one resident with a history of metabolic encephalopathy, heart failure, candidiasis, chronic kidney disease, and other significant comorbidities, enhanced barrier precautions for Candida auris were not properly implemented. There was no signage on the resident's door indicating enhanced barrier precautions, and staff were observed improperly donning and doffing personal protective equipment (PPE), including failing to sanitize hands before donning gloves, dropping clean gloves on the floor and returning them to a pocket, and not properly cleaning hands after removing PPE. Additionally, a CNA was observed removing a gown incorrectly and not performing hand hygiene after glove removal. For another resident with cerebral palsy, contractures, and a gastrostomy, staff were observed gathering wound care supplies with dirty gloves and placing clean bandages on a contaminated surface before use. During wound care, the nurse did not use proper hand sanitizer after each glove change, and the assisting CNA improperly removed her gown and failed to dispose of it correctly. A third resident, who had acute kidney failure and unstageable pressure ulcers, was subjected to cross-contamination when dirty linen was placed on the bed and clean linen was subsequently placed on top of it. The assisting CNA again improperly removed her gown and handled clean linen after contact with contaminated items. Interviews with staff revealed a lack of awareness and training regarding infection control protocols, particularly for residents with fungal infections or those requiring enhanced precautions. The Housekeeping Manager was unaware of CDC cleaning guidelines for fungal infections and did not receive communication from nursing staff about residents on isolation. The Regional Compliance Nurse and other staff members demonstrated gaps in knowledge about infection control procedures and communication processes. Review of facility policies showed that while general infection control measures were outlined, the wound treatment management policy did not address infection control protocols during wound care.
Failure to Monitor and Intervene After Multiple Missed Dialysis Treatments
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the resident, who had multiple diagnoses including chronic kidney disease and was dependent on dialysis, refused three consecutive dialysis treatments. Despite this, there was no documentation of the missed treatments for two of the dates, nor were there documented attempts to send the resident to the hospital for evaluation after missing three treatments. The care plan was only updated to address dialysis non-compliance after the surveyor entered the facility. The resident's medical records indicated significant health concerns, including metabolic encephalopathy, heart failure, diabetes, morbid obesity, COPD, and major depressive disorder. The resident required extensive assistance with most activities of daily living and had moderate cognitive impairment. Laboratory results showed several abnormal values, including elevated glucose, BUN, and creatinine, as well as low albumin and total protein, which were not promptly reviewed or acted upon by the clinical team. The resident reported feeling slightly bloated but otherwise fine, and interviews revealed that the facility staff, including the PA and MD, were aware of the refusals but did not follow established protocols for monitoring or escalation. Interviews with facility staff and the dialysis center social worker highlighted a lack of communication and follow-up after the resident missed multiple dialysis sessions. The facility's policy required documentation and notification when a resident refused dialysis but did not specify follow-up procedures for care after refusal. The PA admitted to not reviewing critical lab results in a timely manner, and the facility did not ensure appropriate monitoring or intervention after repeated missed treatments, placing the resident at risk for delayed medical evaluation and treatment.
Failure to Prevent Resident Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both resident-to-resident physical altercations and staff-to-resident verbal abuse. On the memory care unit, two residents with moderate cognitive impairment and histories of behavioral issues were left unsupervised in a common area. The nurse assigned to the unit, RN K, was in the office with the door closed and did not have visual access to the residents. As a result, a physical altercation occurred in which one resident punched another approximately eight times in the face and head, causing visible injuries including facial swelling and an abrasion. Surveillance video confirmed that the altercation lasted close to two minutes before RN K exited the office and intervened. Staff interviews and documentation revealed that the nurse was slow to respond and did not call for help during the incident. In a separate incident, a resident who was cognitively intact reported being verbally abused by a CNA. The resident stated that after a brief exchange, the CNA used profane language towards him, which made him feel upset and uncomfortable. The incident was corroborated by the resident's roommate and the CNA herself, who admitted to using inappropriate language in response to the resident's provocation. The nurse on duty and the social worker both confirmed that the resident was visibly upset after the incident and that the language used by the CNA constituted verbal abuse. Additionally, another incident involved a resident being physically assaulted by another resident, resulting in the victim being punched in the face. The report details that these failures to provide adequate supervision and to ensure staff refrained from abusive language or behavior led to residents experiencing physical and psychological harm. The facility's lack of timely intervention and failure to maintain a safe environment contributed directly to the deficiencies identified by surveyors.
Failure to Provide Adequate Supervision Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically for two residents on the memory care unit. Both residents had moderate cognitive impairment and dementia diagnoses, with care plans identifying risks for physical aggression and the need for close monitoring. Despite these documented risks, the residents were left unsupervised in a common area, which led to a physical altercation. On the day of the incident, both residents were in the television room when one resident pushed the other, leading to a physical fight in which one resident was punched multiple times in the face and head. The nurse assigned to the unit, RN K, was in the nurse's office with the door closed and did not have visual access to the residents. Surveillance footage showed that the altercation lasted for nearly two minutes before RN K exited the office and intervened. During this time, the residents continued to struggle on the floor, resulting in visible injuries, including facial swelling and abrasions. Interviews and record reviews confirmed that the nurse was slow to respond and did not immediately call for assistance. The CNA on duty was occupied in another room and was unaware of the incident until after it occurred. The lack of adequate supervision and delayed intervention allowed the altercation to escalate, resulting in harm to one of the residents. Staff and leadership interviews further corroborated that the nurse's failure to maintain visual supervision and timely response contributed directly to the incident.
Failure to Timely Submit PASRR Specialized Services Documentation
Penalty
Summary
The facility failed to incorporate recommendations from the PASRR Level II determination and evaluation reports into the assessment, care planning, and transitions of care for two residents who were PASRR positive. For one resident with diagnoses including anxiety disorder, depression, schizophrenia, bipolar disorder, and unspecified intellectual disabilities, the facility did not submit the required Nursing Facility Specialized Services (NFSS) form within 20 business days following an interdisciplinary team (IDT) meeting. The resident's care plan identified the need for specialized services such as customized manual wheelchair, specialized therapy assessments, and habilitation services, all of which were accepted by the resident. However, documentation from the IDT meeting was not uploaded into the required portal in a timely manner, and the Director of Rehabilitation reported delays due to a system glitch and backlog in obtaining physician signatures. Another resident, diagnosed with cerebral palsy, scoliosis, and benign prostatic hyperplasia, also did not have the NFSS form submitted within the required timeframe after an IDT meeting where a customized wheelchair and therapy services were recommended. The Social Services Director was not fully aware of the resident's eligibility for specialized services and was only involved in making ancillary referrals. The Director of Rehabilitation acknowledged responsibility for submitting the NFSS forms and described technical issues with the portal that delayed submission. Despite these delays, the resident continued to receive therapy services, but the process for obtaining a customized wheelchair was delayed due to missed appointments with third-party vendors. Interviews with facility staff, including the Social Services Director, MDS Coordinator, and Administrator, confirmed that the Director of Rehabilitation was responsible for timely submission of required documentation. The facility's policy required NFSS forms to be submitted within 20 business days of the IDT meeting, but this was not consistently followed. The delays in documentation and submission of forms were attributed to technical issues with the portal and internal communication gaps, resulting in the failure to timely incorporate PASRR recommendations into resident care planning and service delivery.
Failure to Immediately Report Alleged Verbal Abuse to Administrator
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to immediately report an allegation of verbal abuse involving a resident and a certified nursing assistant (CNA) to the facility Administrator, as required by policy. The incident involved a male resident with a history of Type 2 Diabetes Mellitus, Chronic Pain Syndrome, and Cognitive Communication Deficit, who was dependent on staff for activities of daily living and had no cognitive impairment. The resident reported that the CNA used profanity towards him, which made him feel upset and uncomfortable. The resident immediately informed the LVN, who then reassigned the CNA but did not notify the Administrator at that time. Interviews revealed that the LVN initially claimed to have reported the incident to the Administrator and Director of Nursing (DON), but later admitted she might not have done so, believing the CNA had already reported it. The DON and Administrator both confirmed that they were not made aware of the incident until the following day, after the resident reported it to the Social Worker. The facility's policy requires all staff to make an immediate verbal report to the Abuse Preventionist or designee when any suspected abuse is identified, regardless of the time of day. The failure to report the allegation immediately delayed the facility's investigation and intervention. The Administrator's contact information was posted throughout the building, and staff were expected to notify her of any abuse allegations without delay. The DON and Administrator both stated that immediate reporting is necessary to ensure resident safety and prevent further harm.
Failure to Protect Residents from Abuse by Staff and Peers
Penalty
Summary
The facility failed to ensure that three residents were free from abuse, resulting in two separate incidents involving both staff-to-resident and resident-to-resident abuse. In the first incident, a male resident with severe cognitive impairment and a history of anxiety disorder and vascular dementia was subjected to emotional and mental abuse by a CNA. Video footage showed the CNA antagonizing the resident, including placing her hand on his knee for an extended period while verbally confronting him about his language and behavior. The resident, who was dependent on staff for activities of daily living and had a care plan addressing behavioral issues, was observed to be verbally aggressive, but the CNA escalated the situation by engaging in a prolonged argument and physical contact that was not necessary for care. The CNA admitted to correcting the resident and acknowledged that her actions were inappropriate. In the second incident, two male residents, one with moderate cognitive impairment and a history of bipolar disorder and dementia, and the other with diagnoses including anxiety disorder and schizoaffective disorder, were involved in a verbal and physical altercation. The altercation began when one resident verbally abused the other by repeatedly calling him derogatory names, despite being asked to stop. This provoked the second resident to physically strike the first resident in the face. The incident was witnessed by a speech and language therapist, who intervened to separate the residents. Both residents had no prior history of physical or verbal behaviors towards others as documented in their assessments, and both were assessed with no injuries following the incident. Both incidents were identified as past noncompliance, with the facility having already addressed the issues before the investigation began. The failures in these cases involved staff engaging in antagonistic and abusive behavior towards a resident, as well as inadequate prevention of resident-to-resident abuse, resulting in emotional, mental, and physical harm. The events placed the affected residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and psychological harm.
Failure to Ensure Wheelchair Safety Features Resulted in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident who used a manual wheelchair with anti-tippers had the anti-tippers removed during a dialysis treatment. The resident, who had a history of depression, obstructive uropathy, diabetes, and limited lower extremity mobility, was assessed as not cognitively impaired and had not experienced prior falls. Despite being care planned for fall risk and having anti-tippers as an intervention, the anti-tippers were removed at the dialysis center at the resident's request, and this change was not communicated to facility staff. Upon returning from dialysis, the resident attempted to board the facility van independently, positioning himself backwards on the van lift against the van driver's repeated instructions to wait for assistance and to face forward. Without the anti-tippers in place, the resident's wheelchair tipped backwards while the lift was flush with the ground, causing him to fall and sustain an abrasion to the back of his head and right elbow. The van driver did not notice the absence of the anti-tippers until after the incident, despite being responsible for ensuring the resident's wheelchair safety features were in place before transport. Multiple interviews confirmed that the anti-tippers were not on the wheelchair at the time of the fall, and that the resident had requested their removal while at the dialysis center. Facility staff, including the van driver and therapy staff, were aware that anti-tippers were a necessary intervention for this resident due to his high fall risk and double amputation. The lack of supervision and failure to ensure the resident's wheelchair was equipped with anti-tippers directly contributed to the fall and injury.
Failure to Accurately Dispense, Administer, and Document PRN Pain Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for two residents reviewed for pharmacy services. For one resident, who had a history of opioid overdose and was discharged from the hospital with explicit orders not to receive opioid medications, a nurse administered hydrocodone/acetaminophen (Norco) despite these restrictions. Documentation was inconsistent, with the narcotic administration record indicating the medication was given, but the medication administration record and progress notes lacking corresponding entries. Interviews with nursing staff and administration confirmed that the hospital discharge orders were not properly followed, and the medication was not discontinued or clarified with the physician as required. For another resident, there were discrepancies between the narcotic administration record and the medication administration record regarding the administration of PRN pain medication. The narcotic log showed multiple instances of hydrocodone/acetaminophen being administered, but the medication administration record did not reflect these doses. Interviews with staff revealed that nurses were not consistently documenting PRN medication administration on both required records, which was acknowledged as a risk for medication errors, double dosing, or potential drug diversion. Facility policy required that all PRN medication orders specify the reason and frequency for use, and that administration be documented on the medication administration record, including symptoms prior to administration and results. The policy also required complete documentation in the nurse's notes or the designated area for PRN documentation. The failure to maintain accurate documentation and to verify current physician orders before administering medications resulted in medication errors and placed residents at risk for adverse outcomes.
Inadequate Supervision and Safety Measures Lead to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents. One resident, who had cognitive impairment and resided on a secure unit, managed to elope from the facility by prying open a window in his room. This resident was found 0.9 miles away from the facility, carrying a dinner knife, a fork, and a shaving razor, and became aggressive when approached by staff. The resident's care plan had identified him as at risk for wandering and elopement, but the facility did not have sufficient measures in place to prevent his escape, such as window alarms or more frequent monitoring. Another resident, who was paraplegic and required assistance with personal care, was not properly secured in a transport van, resulting in a fall that caused a head injury and a contusion on his right hand. The resident was being transported by an outside provider for a medical appointment when the incident occurred. The facility's staff did not ensure that the resident was safely secured in the van, and the transport provider did not properly strap the resident's wheelchair, leading to the fall when the van took off. Both incidents highlight a lack of adequate supervision and safety measures for residents at risk of accidents. The facility's failure to implement effective interventions and monitoring systems for residents with known risks contributed to these deficiencies, resulting in immediate jeopardy situations that required urgent corrective actions.
Removal Plan
- Administrator, DON, and/or designee will initiate an in-service regarding Elopement Response, Elopement Prevention, and Abuse/Neglect. All staff scheduled to work will be in-serviced prior to next shift worked.
- The Administrator will conduct elopement drills.
- The Administrator, DON, and ADON were in-serviced by the ADO and Regional Compliance Nurse on Elopement Prevention Policy to include implementing interventions for residents at risk for elopement, Elopement Response Policy, and Abuse/Neglect.
- Elopement Risks will be completed for all residents on the secured unit.
- AD Hoc QAPI Contributors will meet and review the elopement risk for all residents residing on the secured unit.
- All elopement events were reviewed by the facility QAPI committee members.
- All elopement risk care plan interventions will be reviewed and updated by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned.
- Administrator will monitor the locking mechanism on all the exit doors and windows in the secured unit.
- Administrator will review for 1:1 monitoring in the secured unit.
- Through daily rounds and duties, observe for visitors allowing residents to exit the facility unsupervised.
- Change the door code.
- The medical director was notified of the IJ situation.
- The Administrator will monitor the residents' windows in the secured unit for signs of tampering.
- The Administrator will also monitor the facility entrance and secured unit doors to ensure their locks are functioning properly as well as their alarms.
- Elopement drills will be continued so that all shifts are prepared for elopements.
Delayed Wound Care and Inadequate Response to Resident's Condition
Penalty
Summary
The facility failed to provide timely and appropriate wound care to a resident, leading to a deficiency in care. The resident, who had a history of paraplegia, neurogenic bladder, anxiety disorder, and pressure ulcers, reported feeling unwell and experiencing issues with his wound vacuum on the morning of February 9th. Despite the resident's report of not feeling well and the wound vacuum malfunctioning, RN C did not assess or address the resident's condition until later in the day, resulting in a significant delay in care. RN C acknowledged that the resident appeared pale and unwell, with leaking wounds, but chose to wait for the resident's decision about going to the hospital before proceeding with care. This decision led to a delay of nearly 10 hours before the wound care was addressed, during which time the resident's condition could have worsened. The resident and his family expressed concerns about the lack of timely wound care and the staff's inadequate training in handling wound vacuums. The Director of Nursing (DON) and the Administrator were not informed of the resident's change in condition or the issues with the wound vacuum until much later. The facility's policies on notifying physicians of changes in resident status and ensuring timely wound care were not followed, contributing to the neglect of the resident's needs. The failure to provide timely care and notify appropriate personnel placed the resident at risk of further complications.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure ulcers for a resident who was using a wound vacuum. The resident, who had a history of paraplegia and pressure ulcers, reported to RN C that he was not feeling well and needed his dressing changed due to a leaking wound vac. Despite this report, RN C did not follow up with the resident until approximately 10 hours later, at which point she discovered there were not enough supplies to complete the wound care. This delay resulted in the resident experiencing discomfort and wound drainage on his body, wheelchair, and bed linens. The resident's medical records indicated that he required regular wound care, including the use of a wound vac, which was to be changed on specific days and as needed. However, the records showed that care was not provided on the day the resident reported the issue, nor the following day. Interviews with the resident and his family member revealed ongoing issues with timely and consistent wound care, with staff reportedly lacking the proper training to assist with the wound vacuum. The resident expressed that his condition was not addressed until late in the day, despite his early morning request for care. Interviews with facility staff, including RN C, the DON, and the Administrator, highlighted a lack of communication and training regarding wound care procedures. RN C admitted to not prioritizing the resident's care and not having the necessary supplies, while the DON and Administrator acknowledged the need for staff training and timely response to resident needs. The facility's policies on skin integrity management and physician notification were not adhered to, contributing to the deficiency and placing the resident at risk of further complications.
Failure to Ensure Proper Dialysis Communication
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received appropriate services consistent with professional standards and their care plans. Two residents, both diagnosed with end-stage renal disease, were affected by this deficiency. The facility did not receive dialysis communication forms from the dialysis center for multiple days, which are crucial for maintaining continuity of care. These forms were missing for Resident #9 on ten occasions and for Resident #63 on twelve occasions. Resident #9, a female with intact cognition, and Resident #63, a male with severely impaired cognition, both had care plans that required monitoring for complications from dialysis. Despite this, the facility did not consistently receive or document the necessary communication from the dialysis center. Interviews with the residents confirmed that they attended dialysis sessions regularly and were aware of the forms they were supposed to bring back to the facility. Interviews with facility staff, including a registered nurse, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed a lack of adherence to the facility's dialysis policy. The staff acknowledged the importance of the communication forms for ensuring continuity of care and the potential for missing critical information without them. Despite training on the dialysis communication process, the forms were not consistently collected or followed up on, leading to the deficiency.
Pharmaceutical Service Deficiencies in Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by discrepancies in narcotic logs and expired medications on the 300 Hall nurses' medication cart. Specifically, the narcotic administration records for three residents did not match the actual pill counts in the blister packs. For one resident, the record showed 13 pills remaining, while the blister pack contained 12. Another resident's record indicated 7 pills remaining, but the blister pack had 6. A third resident's record showed 38 pills remaining, while the blister pack had 36. Additionally, a bottle of atropine with an expiration date of August 2024 was found on the cart, indicating a failure to remove expired medications. The report highlights that RN C was responsible for these discrepancies. RN C was observed removing a lorazepam tablet from its packaging and placing it in an unlabeled cup, which she then put in her pocket. She admitted to not administering the medication to the intended resident and failing to notify another nurse for its destruction. Furthermore, RN C did not sign off on the narcotic administration record log after administering medications to two residents, which could lead to potential medication errors. Interviews with the ADON and DON revealed that the facility had policies in place for medication administration and destruction, but these were not followed by RN C. The ADON stated that she expected staff to document medications immediately after administration and to destroy any medication that was removed but not administered. The DON emphasized the importance of proper documentation to prevent overdose and ensure effective resident management. Despite training sessions on medication administration, RN C did not attend these sessions, contributing to the observed deficiencies.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately consult with the physician regarding a significant change in the health status of a resident, identified as Resident #67. This resident, a male with intact cognition and multiple medical conditions including paraplegia and pressure ulcers, reported feeling unwell to RN C. Despite the resident's pale appearance and complaints about his wound vacuum not functioning properly, RN C did not notify the physician or the Director of Nursing (DON) about the resident's condition throughout the shift. Resident #67's medical records indicated that he required regular wound care, including the use of a wound vacuum. On the day in question, the resident approached RN C early in the morning, expressing discomfort and the need for his wound dressing to be changed. However, RN C delayed addressing his needs until late in the afternoon, citing other priorities and a lack of supplies. During this time, the resident's condition was not reassessed, and the physician was not informed of the resident's deteriorating condition. Interviews with the resident, his family member, RN C, the DON, and the physician revealed a lack of timely communication and action regarding the resident's care. The DON and the physician were not informed of the resident's condition change, which could have led to a risk of infection or sepsis. The facility's policy required immediate notification of the physician in such cases, but this protocol was not followed, resulting in a deficiency in the standard of care provided to Resident #67.
Failure to Provide Speech Therapy Evaluation
Penalty
Summary
The facility failed to provide specialized rehabilitative services for a resident who required a speech therapy evaluation as per physician orders. The resident, who had diagnoses including non-traumatic brain dysfunction, non-Alzheimer's dementia, malnutrition, and aphasia, did not receive the necessary speech therapy evaluation. The resident's care plan highlighted a potential risk for malnutrition, and the registered dietician had recommended a speech evaluation. However, the speech therapist was not informed of the order, and the director of rehabilitation did not pass the order to her, resulting in the resident not receiving the evaluation. Interviews revealed a breakdown in communication and process. The speech therapist stated she did not receive a referral, and the DON was unaware of the dietician's recommendation. The registered dietician had emailed the recommendation to several staff members, but the order was not acted upon. The administrator confirmed there was no facility policy regarding therapists following physician orders, which contributed to the oversight. This failure could place residents with therapy orders at risk of not achieving their highest practicable well-being.
Failure to Report Resident Fall Incident
Penalty
Summary
The facility failed to report an alleged violation involving neglect to the State Survey Agency in a timely manner. This incident involved a resident who fell backwards in his wheelchair, which lacked anti-tippers or brakes, hitting his head on the floor of a van during takeoff in the facility parking lot. The resident was sent to the hospital with a head injury and a contusion on his right hand. The resident reported that his wheelchair was not strapped down correctly, leading to the fall and subsequent blackout. The resident, a male with intact cognition, had a history of osteomyelitis, paraplegia, neurogenic bladder, anxiety disorder, and pressure ulcers. His care plan indicated he was at risk for falls due to paraplegia, with goals to prevent falls and serious injuries. On the day of the incident, the resident was being transported by an outside provider for a urology appointment. The Director of Nursing (DON) and the Social Worker were alerted to the incident by the van driver and found the resident in distress, with straps still attached to his wheelchair. The resident was assessed and sent to the hospital for further evaluation. The Administrator did not report the incident to Health and Human Services, believing it was unnecessary since the resident was in the care of an outside provider. The facility's policy required event reporting for incidents resulting in a change in resident status, but the Administrator assumed the transport company would handle the reporting. This oversight placed the resident at risk of further accidents and injury, as the incident was not reported within the required timeframe.
Failure to Investigate and Report Allegation of Neglect
Penalty
Summary
The facility failed to investigate and report an allegation of neglect involving a resident who fell backwards in his wheelchair while being transported by an outside provider. The incident occurred when the resident's wheelchair, which lacked anti-tippers or brakes, was not properly secured in the transport van. As a result, the resident hit his head on the floor of the van during takeoff, leading to a head injury and a contusion on his right hand. Despite the severity of the incident, the facility did not conduct a thorough investigation or report the event to the state agency as required. The resident involved in the incident was a male with a history of paraplegia, osteomyelitis, neurogenic bladder, anxiety disorder, and pressure ulcers. His cognitive function was intact, as indicated by a BIMS score of 14. On the day of the incident, the resident was being transported to a urology appointment by an outside provider because the facility's van was unavailable. During the transport, the resident reported that the van driver took off abruptly, causing him to fall and hit his head. The resident was subsequently sent to the hospital for evaluation and treatment. Interviews with facility staff, including the Director of Nursing (DON), Social Worker, and Administrator, revealed a lack of communication and responsibility in handling the incident. The DON and Social Worker were aware of the incident but did not ensure that an investigation was completed or that the state agency was notified. The Administrator, who was present at the scene, did not conduct an investigation or report the incident, believing that the responsibility lay with the transport company. This failure to act placed the resident and potentially other residents at risk of further harm.
Failure to Properly Label and Store Insulin Vials
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of drugs and biologicals, specifically insulin vials, on one of the medication carts reviewed. During an observation, it was found that an insulin vial of Humalog was opened and partially used without being labeled with the open date. Additionally, a vial of Levemir was found with an incorrect date. This oversight was identified on the medication cart for Hall 200, which was under the responsibility of RN C. Interviews with RN C, the ADON, and the DON revealed a lack of adherence to the facility's policy requiring insulin vials to be dated upon opening. RN C admitted to not checking the cart for proper labeling and expired medications on the day of the observation. The ADON and DON both acknowledged the expectation for nurses to date insulin vials and the ADON's responsibility to monitor compliance weekly. However, there was no documentation provided to confirm recent training on these procedures, and the last cart check by the ADON was over a week prior to the observation.
Failure to Provide Adequate Supervision and Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who required two staff members for assistance with all activities of daily living (ADLs). On the day of the incident, a Certified Nursing Assistant (CNA) provided a bed bath to the resident without the required assistance from another staff member. During the bed bath, the CNA asked the resident to turn to her side, which resulted in the resident falling to the floor and sustaining a fracture of her right femur. The resident involved was a female with a history of hypertension, seizure disorder, cellulitis, fibromyalgia, and muscle wasting. Her cognitive abilities were moderately impaired, and she was dependent on staff for showering and bathing, requiring the assistance of two or more helpers. Despite this, the CNA proceeded to bathe the resident alone, citing an inability to find another staff member to assist, even though the resident's care plan and Kardex system clearly indicated the need for two staff members. Interviews with various staff members, including other CNAs and nurses, confirmed that the resident was known to require two staff members for all care due to her bariatric status and safety concerns. The CNA involved admitted to knowing the requirement but chose to proceed alone, which directly led to the resident's fall and subsequent injury. The incident highlights a lapse in adherence to established care protocols and the failure to ensure the resident's safety during care.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. The resident, a male with multiple diagnoses including chronic kidney disease and urine retention, was readmitted to the facility after a hospital stay. Despite the care plan identifying a potential fluid deficit and the need to monitor signs of dehydration, there was no evidence of implementation in the resident's care tasks, TAR/NMAR, or eMAR for October 2024. Observations revealed that the resident's catheter urine collection bag had no urine output on multiple occasions, indicating a lack of monitoring for dehydration. Interviews with facility staff, including medical assistants, nurses, and the ADON, highlighted inconsistencies in monitoring and documenting the resident's urine output. Staff members were aware of the need to monitor urine output, but the care plan was not updated to reflect this requirement, and the necessary documentation was missing from the resident's records. The facility's policy required the development of a comprehensive care plan to meet the resident's needs, but this was not effectively implemented. Interviews with the Administrator and DON confirmed that the lack of monitoring could lead to dehydration or a UTI, and they acknowledged the importance of updating care plans during IDT meetings. However, the deficiency in implementing the care plan placed the resident at risk of not receiving necessary care and services.
Deficiency in Monitoring Urine Output and Dehydration
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a deficiency in monitoring and documenting signs and symptoms of dehydration and urine output. The resident, a male with multiple diagnoses including intellectual disability, chronic kidney disease, and urine retention, was readmitted to the facility after a hospital stay. Despite the care plan indicating the need to monitor for signs of dehydration, there was no documentation or care tasks related to this monitoring in the resident's records for October 2024. Observations revealed that the resident's catheter urine collection bag had no urine output on multiple occasions, and interviews with staff indicated a lack of consistent monitoring and documentation of urine output. The resident himself reported that his catheter bag had not been emptied since early morning, and staff interviews revealed confusion about the monitoring process. The Treatment Nurse and other staff members acknowledged the need for monitoring urine output, but there was no evidence of this being done consistently or documented in the resident's electronic medical records. The facility's policy required comprehensive care plans to describe the services needed to maintain the resident's well-being, but the lack of monitoring and documentation for this resident's urine output and potential dehydration indicated a failure to adhere to this policy. Interviews with the Administrator and DON confirmed that the absence of monitoring could lead to serious health issues such as UTIs or dehydration, highlighting the deficiency in care provided to the resident.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as observed with one of the six medication carts located on Hall 200. On two separate occasions, the medication cart was found unlocked and unattended. On the first occasion, an LVN left the cart unlocked at 12:30 PM, and it was later locked by the DON at 12:45 PM. On the second occasion, another LVN left the cart unlocked at 9:26 PM, shortly after arriving at the facility. Interviews with the involved LVNs revealed that they were aware of the requirement to lock the medication cart when not in use, acknowledging the risk of residents or staff accessing the medications. The facility's Medication Administration Procedures policy, revised in 2017, mandates that the medication cart must be completely locked after the medication administration process is completed. The Administrator and the DON confirmed that the nursing staff is responsible for ensuring the cart is locked before leaving it unattended.
Resident Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the call light for a resident was not within reach, as it was draped over the headboard of a vacant bed on the other side of a privacy curtain. This oversight was observed during a survey, and the resident, who was moderately cognitively intact and required maximum assistance for toileting and showers, was unable to locate the call light. The resident reported not calling for help and mentioned a recent fall while transferring herself to her wheelchair. Interviews with various staff members, including the Director of Nursing (DON), Licensed Vocational Nurse (LVN), Certified Nursing Assistants (CNAs), and the Regional Compliance Nurse, revealed that they were unaware of the call light's inaccessibility. They acknowledged that the call light should be accessible to all residents to ensure they can call for assistance. The facility's Administrator stated that managers conducted Champion Rounds to check on call lights and other resident needs, but the deficiency was not addressed. The facility's Resident Rights policy emphasized the importance of residents' rights to communication and access to services, which was not upheld in this instance.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who was reviewed for accidents. The resident, who had a history of falls and was severely cognitively impaired, fell from her bed and was found face down on the floor with a bruise on her forehead. At the time of the fall, the resident did not have a fall mat placed on both sides of her bed, which was a necessary intervention to prevent injury from falls. The resident's care plan, which was updated after the incident, initially did not include orders for fall mats as a fall intervention. The facility's staff, including the Director of Nursing and the Regional Compliance Nurse, acknowledged that a fall mat was only placed on one side of the bed, leaving the resident at risk of injury. Interviews with staff revealed that the resident was often combative, required a mechanical lift for transfers, and that the bed was not against the wall to facilitate staff assistance. The facility's Fall Risk Assessment policy emphasized the need for appropriate interventions to be addressed immediately on the interdisciplinary plan of care. However, the lack of a fall mat on both sides of the resident's bed was a significant oversight. The incident was unwitnessed, and the resident was found by a CNA during routine rounds. The facility's failure to implement adequate fall prevention measures contributed to the resident's fall and subsequent injury.
Resident Suffers Burn Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who suffered a burn blister on her left wrist. The incident occurred when the resident, who had severe cognitive impairment and required supervision for eating, spilled hot coffee on herself in the dining room. The resident was wearing gloves to prevent scratching her skin, which caused her to lose grip of the cup, resulting in the spill. The resident did not report the incident immediately as she did not feel pain at the time and only noticed the blister later when it started to itch. The resident had a history of cerebrovascular accident, transient ischemic attack, and non-Alzheimer's dementia, which contributed to her need for supervision. The facility's investigation revealed that the resident had gone to the dining room after breakfast to get another cup of coffee and spilled it due to her gloves. The coffee temperature logs indicated that the coffee was served at the correct temperature, but the resident's cognitive impairment and physical limitations were not adequately addressed to prevent the accident. The facility's care plan for the resident included interventions to prevent burns from hot liquids, such as ensuring the coffee was not served over 140 degrees Fahrenheit and that the resident should be seated in an upright position with a table when consuming hot liquids. However, these interventions were not effectively implemented, leading to the resident's injury. The facility's failure to provide adequate supervision and assistance devices for the resident resulted in the burn incident.
Improper Storage of Razors in Shower Room
Penalty
Summary
The facility failed to ensure that disposable razors in one of the shower rooms were kept out of reach of residents, which could potentially lead to accidents or injuries. During an observation and interview, it was noted that two navy blue disposable razors were placed on top of the sharps container in the shower room, making them accessible to residents. CNA A confirmed that razors should be locked in a closet within the shower room and discarded in the sharps container after use. However, the razors were left on top of the sharps container, posing a risk to residents who might use them unsupervised, potentially leading to self-harm or harm to others. Further interviews with RN B and the ADON revealed that CNAs were responsible for showering and shaving residents and were expected to dispose of razors properly after use. RN B acknowledged the risk of infection and injury if razors were not disposed of correctly. The ADON confirmed that all staff were responsible for ensuring razors were placed in the sharps container and expressed uncertainty about why the razors were left out. The facility's policy on shaving indicated that all articles should be stored appropriately, yet this protocol was not followed, leading to the deficiency.
Failure to Designate Full-Time DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis for 53 out of 65 days reviewed. This deficiency was identified during an interview with the Administrator, who confirmed that the last dedicated DON was in place on 04/12/24. Since then, the responsibilities of the DON have been divided among the Assistant Director of Nursing (ADON), the MDS Coordinator, and the Regional Compliance Nurse, none of whom were dedicated to the DON position for 8 hours a day. The Administrator admitted to not having a policy regarding DON coverage, and the ADON confirmed that she, along with the MDS Coordinator and the Regional Compliance Nurse, were covering the DON duties while also performing their regular roles.
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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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