Five Points Of Pflugerville
Inspection history, citations, penalties and survey trends for this long-term care facility in Pflugerville, Texas.
- Location
- 521 S Heatherwilde Blvd, Pflugerville, Texas 78660
- CMS Provider Number
- 675913
- Inspections on file
- 52
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Five Points Of Pflugerville during CMS and state inspections, most recent first.
A cognitively impaired male resident with schizophrenia, major depressive disorder, and generalized anxiety disorder became upset during care when a CNA controlled his bed remote and did not comply with his request. During in-room care with two other CNAs present, the resident used profanity toward the CNA, and the CNA responded by yelling back and using profane, derogatory language, including statements about cleaning the resident and asserting her own rights. Other CNAs reported hearing the CNA curse at the resident, and the LVN on duty was informed of an altercation and spoke with the resident about what occurred. In a later interview, the CNA admitted repeating the resident’s profane remarks back to him. The facility’s abuse policy defined verbal abuse as willful use of disparaging or derogatory language toward a resident, and the CNA had previously been trained on abuse/neglect and resident rights.
Staff were observed serving food trays to residents without performing hand hygiene between each resident. Two newly hired CNAs admitted to forgetting to use hand hygiene despite having received training. Other staff, including an LVN and the DON, confirmed that hand hygiene is required by facility policy when serving meals.
The facility did not ensure accurate documentation of overnight care for four residents, including one on hospice who was found deceased, with no records of care or monitoring from 10:00 p.m. to 6:00 a.m. Staff interviews revealed inconsistent understanding of documentation expectations, and review of records showed missing entries for required ADL assistance and monitoring, despite care plans mandating frequent checks and interventions.
A resident with multiple medical and cognitive conditions was issued a discharge notice for non-payment, but the facility did not provide a discharge summary, plan, or adequate notification to the resident, responsible party, or ombudsman. The discharge notice lacked a specific destination, and staff interviews revealed no finalized discharge plan or proper communication, contrary to facility policy.
The facility failed to update the care plans for three residents to reflect changes in their activity levels, placing them at risk of not having their needs reviewed and revised appropriately. The Activity Director acknowledged that the care plans should have been revised to reflect the residents' current activity needs, as the lack of updates could affect their quality of life and mood.
The facility failed to provide adequate personal hygiene and grooming for three residents, leading to deficiencies in nail care and facial hair management. A resident with severe cognitive impairment was found with unclean and uneven fingernails, while another resident with Alzheimer's disease had unclean and rough nails. Additionally, a female resident with multiple health conditions was observed with facial hair, indicating a lack of adherence to grooming care plans. Staff interviews revealed inconsistencies in care documentation and awareness of care schedules.
The facility failed to ensure the Dietary Manager (DM) wore a beard guard properly while in the kitchen, as observed over three days. The DM was seen with facial hair visible during food preparation and service, contrary to the facility's dress code policy. Interviews confirmed that hair restraints are required to prevent contamination, and the DM is responsible for enforcing this policy.
A facility failed to maintain an effective infection control program as Student Nurse A and Student Nurse Aide G did not perform hand hygiene between resident interactions during meal service. They touched contaminated surfaces before handling food for multiple residents, despite being trained on infection control. Staff interviews confirmed the expectation for hand hygiene to prevent cross-contamination, which was not adhered to, posing a risk of bacterial contamination.
The facility failed to serve meals to residents in a timely and organized manner, affecting their dignity and quality of life. Three residents were served at different times, contrary to the facility's policy of serving all residents at a table before moving to the next. The DON and ADM acknowledged the lack of communication between nursing and dietary staff, which led to this issue.
A facility failed to implement a comprehensive care plan for a resident with multiple diagnoses, including toxic encephalopathy and parkinsonism, who was at risk for falls. The care plan required a fall mat beside the bed and the bed in the lowest position, but observations showed the mat was not consistently in place, and the bed was not always lowered. Staff interviews confirmed the expectation for fall mats to be in place, but the facility did not adhere to this requirement.
The facility failed to provide individualized activities for three residents with cognitive and physical impairments, leading to a deficiency in meeting their well-being needs. Despite care plans requiring one-on-one activities, these residents received minimal engagement, with staff acknowledging the difficulty in providing consistent activities due to facility constraints.
A resident with multiple health conditions did not have his meal preferences obtained or RD recommendations for snacks and supplements implemented, leading to dissatisfaction with meals and potential health risks. The facility failed to follow its policy on meal service and snacks, and the discontinuation of nutritional supplements was done without proper consultation.
The facility failed to properly store Probiotics in the medication refrigerator on the secure unit, where they were kept with staff food and drinks. Staff interviews revealed that all staff had access to the refrigerator, and there was no temperature log maintained. The Director of Nurses acknowledged that medications should not be stored with food and drinks and that the Probiotics should have been in the medication room.
A resident with severe cognitive impairment did not receive meals according to his preference for large portions, as documented in his care plan and physician orders. Despite expectations for dietary staff and nurses to ensure meal tickets matched the meals served, the resident received a normal portion size, contrary to his documented preferences.
A resident with dementia and a history of falls was moved by a CNA without a nurse's assessment after an unwitnessed fall, contrary to facility policy. The CNA panicked and moved the resident to a wheelchair, risking potential harm. The resident was later assessed by an LVN and found uninjured.
A resident with osteoporosis was not transferred according to her care plan, resulting in her sliding to the ground and sustaining femur fractures. Staff failed to use a hoyer lift as required, and the incident was not documented or assessed as a fall. The resident later died from complications following surgery. The facility's policies on transfer protocols and documentation were not adhered to, leading to this deficiency.
A resident in an LTC facility was not transferred according to her care plan, which required a hoyer lift with two-person assistance. Instead, staff attempted to transfer her without the lift, resulting in her sliding to the ground. The incident was not immediately reported or documented, and the resident later developed bilateral femur fractures, leading to her death after surgery. Staff interviews revealed a lack of awareness of the resident's transfer status and failure to adhere to facility policies.
The facility failed to document and report changes in skin condition for two residents, both with severe cognitive impairment. One resident had a dark purple blister on his finger, and another had a bruise and skin tear, none of which were documented in their charts. Staff interviews revealed a lack of awareness and documentation, contrary to facility policies requiring skin assessments and notifications.
A resident on Eliquis was unable to undergo a scheduled tooth extraction because the facility failed to hold the medication as recommended. Despite the resident's request for dental services due to pain, the procedure was canceled, causing ongoing discomfort and frustration. Interviews revealed a breakdown in communication and procedure adherence, as the recommendation to hold the blood thinner was not properly entered into the system.
The facility failed to provide adequate supervision to prevent falls for two residents, resulting in one resident sustaining a hip fracture. Despite having care plans with specific fall prevention interventions, the facility did not consistently implement these measures, and fall risk assessments were not completed as required.
The facility failed to meet PASARR requirements for a resident who needed a customized manual wheelchair (CMWC). The wheelchair was approved on 2/15/24, but the facility did not order it until 2/26/24, missing the 2/22/24 deadline. This delay caused a postponement in the resident receiving her Medicaid Entitled Service, impacting her ability to participate in necessary therapies and mobility activities.
Verbal Abuse of Cognitively Impaired Resident by CNA During Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA during personal care. The resident was an adult male with schizophrenia, major depressive disorder, and generalized anxiety disorder, and had a BIMS score of 06 on a recent MDS, indicating severely impaired cognition. His care plan noted a potential for verbally abusive behaviors, with an intervention to notify the charge nurse of any abusive behaviors. On the day of the incident, the resident became upset when a CNA did not change the television channel as requested, and later during care an altercation occurred between the resident and the CNA. According to written statements from two CNAs, three CNAs, including the alleged perpetrator, were in the resident’s room to change him. One CNA reported that after they finished changing the resident, the involved CNA began cursing at the resident, telling him, "fuck me, no fuck yourself, you stupid ass. I have rights just like you," and appeared very upset. Another CNA stated that the resident had asked for the bed remote control, that it dropped on him, and that he yelled "Fuck you!" at the CNA. This CNA reported that the involved CNA yelled back at the resident, saying, "We are here cleaning your ass! Don't tell us Fuck you!," and that both the resident and the CNA were yelling at each other. The LVN on duty documented that a CNA reported the altercation to him and that he then spoke with the resident, who described what had happened. In a subsequent phone interview, the involved CNA acknowledged that she was assisting two other CNAs, that the bed remote dropped on the resident, and that the resident called her an "ugly fucking face." She stated that she told the resident he was not to speak to her that way and repeated his words back to him, and that the other CNAs only heard her repeating those words. The administrator later confirmed that an investigation determined the CNA had been verbally abusive to the resident, and that the CNA had previously received training on abuse/neglect and resident rights. The facility’s Abuse/Neglect Policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff on the 500 Hall were observed distributing and serving food trays to residents without performing hand hygiene between residents. Specifically, two CNAs were seen passing food trays, touching residents' doors, setting up trays, and moving the food cart without cleaning their hands between each resident. Both CNAs were new to the facility and reported having received hand hygiene training during orientation, but admitted to forgetting to perform hand hygiene during meal service. Interviews with additional staff, including an LVN, another CNA, and the DON, confirmed that facility policy requires hand hygiene before and after assisting residents with meals. The LVN and DON both acknowledged that failure to perform hand hygiene when serving food constitutes an infection control issue. Review of the facility's hand hygiene policy also indicated that hand hygiene is required before and after assisting a resident with meals.
Failure to Document Overnight Care for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation of care provided to four residents during the overnight shift from 10:00 p.m. to 6:00 a.m. on the dates reviewed. For one resident who was on hospice care and found deceased around 6:00 a.m., there was no documentation of care provided during the night, nor any record of a change in condition that would have required intervention. The resident's care plan required two CNAs for bed mobility and mechanical lift transfers, and staff were expected to provide incontinent care and repositioning at least every two hours. However, the resident's progress notes, medication administration records, and point-of-care documentation lacked entries for the entire overnight period, except for a single set of vital signs recorded at 1:27 a.m. The postmortem assessment indicated the resident was found unresponsive, cold to the touch, and with fixed and dilated pupils, with no evidence of care or monitoring during the preceding shift. Similarly, three other residents, all with significant cognitive and physical impairments and dependent on staff for all activities of daily living, had no documentation of care provided during the same overnight shift. Their care plans also required frequent assistance, including turning, repositioning, and incontinent care at least every two hours. Review of their point-of-care records revealed no entries for any care activities during the specified time frame. Staff interviews confirmed that CNAs and nurses were responsible for providing and documenting care at least every two hours, and that documentation was expected to be completed in the electronic health record after each task. Interviews with staff, including CNAs, nurses, the ADON, and the medical director, revealed inconsistent understanding of the facility's expectations for resident checks and documentation frequency. While some staff stated that care should be provided and documented every two hours, others were unclear about the specific requirements. The facility lacked a formal policy on rounding or checking on residents, and the documentation policy emphasized the need for timely, accurate, and complete entries in the clinical record. Despite these expectations, the absence of documentation for multiple residents during the overnight shift indicated a failure to maintain accurate medical records in accordance with professional standards.
Failure to Provide Proper Discharge Documentation and Planning
Penalty
Summary
The facility failed to properly discharge a resident by not providing all necessary information and documentation required for a safe and effective transition of care. The resident, who had significant medical and cognitive impairments including vascular dementia, major depressive disorder, type 2 diabetes with neuropathy, and bilateral below-knee amputations, was not his own responsible party. The facility issued a discharge notice for non-payment but did not document a discharge summary, discharge plan, or provide adequate notification to the resident, responsible party, or ombudsman. The discharge notice also lacked a specific address for the resident's discharge destination. Record review showed no evidence of discharge planning discussions or documentation in the nursing progress notes. Interviews with facility staff revealed that the discharge process was still ongoing, with no finalized plan or summary in place. The ombudsman and responsible party were not properly informed, and there was confusion among staff regarding the resident's discharge status and destination. The resident expressed concerns about not receiving sufficient help with his Medicaid application and uncertainty about his ability to return home, while the responsible party indicated the resident's previous home was uninhabitable and that family support was unavailable. Facility policy requires documentation of the basis for discharge and a plan to ensure a safe transition, but these steps were not followed. The lack of a documented discharge summary, plan, and proper notification could compromise the resident's continuity of care and transition to an appropriate setting, as the facility had not determined a safe discharge location or communicated effectively with all involved parties.
Failure to Update Care Plans for Residents' Activity Needs
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for three residents were reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for three out of eight residents reviewed for care plans. The care plans for these residents were not updated to reflect changes in their activity levels, which placed them at risk of not having their needs reviewed and revised as necessary to ensure appropriate care. Resident #47, a female with cerebral palsy, severe intellectual disabilities, and autism, had a care plan that did not reflect her need for one-on-one activities. Despite her activity preference for watching cartoons and listening to music, her care plan was not updated to indicate her need for individualized activities. The Activity Director acknowledged that the care plan should have been revised to reflect these needs, as the lack of updates could affect the resident's quality of life, potentially leading to feelings of isolation or depression. Similarly, Resident #59, who had diagnoses including Alzheimer's disease and chronic pain, was not provided with an updated care plan to reflect her need for one-on-one activities. Although her activity participation record indicated she required one-on-one interaction five days a week, this was not documented in her care plan. The Activity Director admitted that the care plan should have been revised to match the resident's current activity needs. Resident #70, with vascular dementia and visual impairments, also had a care plan that was not updated to reflect her preference for one-on-one visits in her room. The Activity Director confirmed that the care plan should have been revised to document this preference, as the lack of documentation could lead to the resident being encouraged to participate in activities she did not prefer, potentially affecting her mood and behavior.
Deficiencies in Personal Hygiene and Grooming for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, leading to deficiencies in personal hygiene and grooming. Resident #20, a male with severe cognitive impairment and multiple health conditions, was observed with unclean and uneven fingernails, despite requiring assistance with personal hygiene. The care plan for Resident #20 included regular nail care, but observations revealed a lack of adherence to this plan, as the resident's nails were not properly maintained. Similarly, Resident #77, a female with Alzheimer's disease and severe cognitive impairment, was found with unclean and rough fingernails. Despite the care plan specifying the need for assistance with personal hygiene, including nail care, the resident's nails were not adequately maintained. Interviews with staff indicated a lack of awareness regarding the last time the resident's nails were trimmed or cleaned, and there was no documentation of refusal of care by the resident. Resident #56, a female with severe cognitive impairment and multiple health conditions, was observed with facial hair, indicating a failure to provide adequate grooming. The care plan required regular shaving during scheduled showers, but the resident was observed with facial hair over several days. Interviews with staff revealed inconsistencies in documenting care refusals and a lack of adherence to the care plan. The Director of Nursing acknowledged the expectation for female residents to be shaved unless otherwise documented, but there was no explanation for the lack of documentation regarding the resident's refusal of care.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the use of hair restraints in the kitchen. Observations over three consecutive days revealed that the Dietary Manager (DM) did not properly wear a beard guard, leaving facial hair visible while serving and preparing food. This was noted during lunch meal service and food preparation activities, where the DM was seen with the beard guard down under the chin, contrary to the facility's dress code policy. Interviews with the DM, Director of Nursing (DON), and Administrator (ADM) confirmed that hair restraints, including beard guards, are required for all kitchen staff to prevent hair from contaminating food. The DM acknowledged the requirement but could not explain why he failed to comply. Both the DON and ADM emphasized that the DM is responsible for ensuring compliance with hair restraint policies in the kitchen. The facility's dress code policy mandates that dietary staff with facial hair must wear beard nets while in the dietary department.
Inadequate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of Student Nurse A and Student Nurse Aide G. During a lunch tray pass, Student Nurse A was observed delivering meal trays to multiple residents without performing hand hygiene between each interaction. She touched contaminated surfaces such as her shirt, wheelchair armrests, and the clothes of other residents before handling the food of Residents #33, #44, #7, and #36. Despite being in-serviced on hand hygiene and infection control, she admitted to possibly forgetting to sanitize her hands during the process. Similarly, Student Nurse Aide G was observed delivering meal trays in the dining room without washing or sanitizing his hands after touching potentially contaminated surfaces, including his scrub top and the armrests of wheelchairs. He handled the food of Residents #17 and #51 without performing hand hygiene, acknowledging the potential for cross-contamination. Despite receiving training on infection control and hand hygiene, he failed to adhere to the facility's policies during the meal service. Interviews with facility staff, including LVN B, the DON, and the ADM, confirmed that the expectation was for all staff to perform hand hygiene between each resident interaction to prevent cross-contamination and potential illness. The facility's policies on hand hygiene and infection control were not followed, leading to a risk of bacterial contamination and potential gastrointestinal illness among residents.
Failure to Ensure Timely Meal Service for Residents
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal service, affecting three residents. Resident #15, a male with severe cognitive impairment and multiple health issues, was served his meal at 12:00 PM, but no other residents in the dining room were served until 12:50 PM. Resident #50, a female with intact cognition and various health conditions, was served at 12:23 PM and was sitting alone. Resident #52, a female with severe cognitive impairment and several health diagnoses, was served at 12:37 PM while sitting with three other residents. The facility's dining room etiquette policy requires that all residents at a table be served before moving to another table, which was not followed. The Director of Nursing (DON) acknowledged that it is best practice for all residents to be served meals simultaneously, but this did not occur due to a lack of communication between nursing and dietary staff. The Administrator (ADM) also stated that it was expected for each table to be completely served before moving to the next, and that communication between nursing staff and the Dietary Manager (DM) was necessary to ensure this. The failure to serve meals in a timely and organized manner could place residents at risk of diminished dignity and affect their quality of life. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, and promoting an environment that enhances their quality of life. However, the observed meal service did not align with these standards, as residents were served at different times, leading to potential feelings of neglect or isolation.
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 meet the resident's needs. The resident, a male with multiple diagnoses including toxic encephalopathy, malignant neoplasm of the temporal lobe, major depressive disorder, parkinsonism, hypertension, GERD, and cerebral edema, was at risk for falls due to an unsteady gait and combative behavior. The care plan specified that the bed should be in the lowest position with a fall mat in place beside the bed. However, observations revealed that the fall mat was not consistently placed beside the bed as required, and the bed was not always in the lowest position. Interviews with staff, including a CNA and the DON, confirmed that the fall mat was supposed to remain on the floor beside the resident's bed when the resident was in bed. The DON acknowledged that the fall mat was not consistently in place and could not explain why it was moved. The ADM also stated that the expectation was for fall mats to be in place to prevent significant injuries from falls. The facility's policy required the development and implementation of a comprehensive care plan to meet the resident's needs, but this was not adhered to, as evidenced by the improper placement of the fall mat and bed position.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs and preferences of three residents, leading to a deficiency in meeting their physical, mental, and psychosocial well-being. Resident #47, a female with cerebral palsy, severe intellectual disabilities, and autism, was supposed to receive one-on-one activities three times per week. However, during the months of January to March 2025, she only received such activities on two occasions. Observations showed that she was often left without stimulation in her room, and the Activity Director admitted to not knowing how to accommodate her communication needs. Resident #70, a female with vascular dementia and severe visual impairment, was also supposed to receive one-on-one activities three times per week. Despite her preferences for listening to music and being around animals, she only received one-on-one activities sporadically, with no visits recorded in March 2025. The Activity Director acknowledged the difficulty in providing consistent activities due to the facility's census and did not provide a reason for the lack of activities for Resident #70. Resident #59, a female with Alzheimer's disease and a language barrier, was to receive one-on-one activities five days a week. However, there was no documentation of her receiving any such activities during February and March 2025. The Activity Director noted that Resident #59's physical decline made it difficult for her to participate in group activities, and her family requested she not be isolated in her room. The lack of activities for these residents was confirmed by interviews with staff, who noted the residents' need for culturally and mentally appropriate activities.
Failure to Implement Resident's Dietary Preferences and RD Recommendations
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 facility did not obtain the resident's meal preferences, which is a critical component of personalized care. The resident, who has a history of alcohol dependence with alcohol-induced dementia, anemia, hypertension, hyperlipidemia, muscle wasting, and chronic kidney disease, expressed dissatisfaction with the food, stating it was cold and unpalatable. The resident also reported never having been consulted about meal preferences and not receiving snacks between meals, which he found necessary due to frequent hunger. The facility also failed to implement and monitor the registered dietitian's (RD) recommendations for snacks with protein and Med Pass 2.0, a nutritional supplement, which were ordered but later discontinued without proper communication or documentation. The Director of Nursing (DON) acknowledged that the orders were discontinued without consulting the RD or physician, despite the resident being under his ideal body weight (IBW). The resident had refused the Med Pass 7 out of 24 times it was administered, which led to the discontinuation of the orders without exploring alternative supplements. Interviews with the Dietary Manager (DM) and the Administrator (ADM) revealed a lack of clarity and responsibility in obtaining and updating the resident's dietary preferences and implementing RD recommendations. The DM admitted to not having a dietary profile for the resident and acknowledged the potential negative impact on the resident's intake and health. The ADM confirmed that it was the DM's responsibility to obtain meal preferences and that the failure to do so could lead to decreased intake and weight loss. The facility's policy on meal service and snacks was not followed, as the resident did not receive the recommended snacks or have his preferences recorded and honored.
Improper Storage of Medications with Staff Food
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, specifically Probiotics, in the medication refrigerator located in the secure unit's dining room. The Probiotics were stored alongside staff food and open drink containers, which is against the facility's medication storage policy. Interviews with staff, including an LVN and a CNA, revealed that all staff had access to the refrigerator, and they were aware that medications should be locked but could not recall the date of their in-service training on this policy. Additionally, there was no temperature log for the refrigerator on the secure unit, and the LVN confirmed that temperatures were not documented. The Director of Nurses stated that the Probiotics should have been stored in the medication refrigerator in the medication room, not on the secure unit, and acknowledged that it was not best practice to store medications with staff food and drinks. The facility's medication storage policy was requested but not provided at the time of the survey exit.
Failure to Honor Resident's Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodates a resident's preferences, specifically for a resident who requested large portions as per his care plan and meal ticket. The resident, who had a severely impaired cognition with a BIMS score of 5, was on a regular diet with a preference for large portions and no pork. Despite these documented preferences, the resident received a normal portion size meal, which did not align with his care plan or physician orders. Interviews with the Dietary Manager, Director of Nurses, and RN A revealed that there was an expectation for the dietary staff and nurses to ensure that meal tickets matched the residents' meals. The Dietary Manager and Director of Nurses confirmed that the resident was expected to receive double portions, and the nurse was responsible for checking the meal ticket against the meal tray. However, this process was not followed, leading to the resident not receiving the correct meal portions as per his preferences and care plan.
Failure to Assess Resident Before Moving After Fall
Penalty
Summary
The facility failed to ensure that a resident received appropriate assessment and care following an unwitnessed fall. A resident, who had a history of dementia, repeated falls, and age-related physical debility, was found on the floor by a CNA. Despite knowing the protocol, the CNA panicked and moved the resident to a wheelchair without first having a nurse assess him. This action was contrary to the facility's policy, which requires a nurse to assess a resident for potential injuries before moving them after a fall. The resident's care plan indicated a high risk for falls, and the facility's policy emphasized the importance of nurse assessment to prevent further injury. The CNA admitted to the mistake, acknowledging the importance of a nurse's assessment in such situations. The incident was reported to the nurse practitioner, and the Director of Nursing confirmed that the resident was later assessed by an LVN and found to be uninjured. However, the initial failure to follow protocol could have placed the resident at risk of harm.
Failure to Follow Transfer Protocols Leads to Resident's Injury and Death
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. The resident, who was diagnosed with age-related osteoporosis, was supposed to be transferred using a hoyer lift with two-person assistance. However, on two occasions, the resident was not transferred according to her transfer status. On the first occasion, LVN A and CNA B attempted to transfer the resident without the hoyer lift, resulting in the resident sliding to the ground. Subsequently, LVN A, CNA B, and CNA C transferred her from the ground to the bed without using the hoyer lift. Approximately 24 hours after the inappropriate transfer, the resident's legs were swollen, red, and warm to the touch. She was transferred to the emergency room, where she was diagnosed with two femur fractures. During surgery to repair the fractures, the resident suffered an embolism and passed away. The facility also failed to ensure that LVN A completed a fall assessment or documented the incident after the resident slid to the ground during the inappropriate transfer. Interviews with staff revealed that they were unaware of the resident's transfer status and did not consider the incident a fall at the time. The facility's policies on hydraulic lift usage, fall prevention, and documentation were not followed, leading to the resident's injury and subsequent death. The noncompliance was identified as past non-compliance, and the immediate jeopardy situation began and ended on specific dates, with the facility correcting the noncompliance before the survey began.
Failure to Follow Transfer Protocols Leads to Resident's Injury and Death
Penalty
Summary
The facility failed to ensure a safe environment for a resident, who was supposed to be transferred using a hoyer lift with two-person assistance. On two occasions, the resident was not transferred according to her transfer status. During the first incident, a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) attempted to transfer the resident without the hoyer lift, resulting in the resident sliding to the ground. Subsequently, the resident was transferred back to her bed without the use of the hoyer lift, contrary to her care plan requirements. Approximately 24 hours after the inappropriate transfer, the resident exhibited symptoms of swelling, redness, and warmth in her legs. She was then transferred to the emergency room, where she was diagnosed with bilateral femur fractures. During surgery to repair the fractures, the resident suffered an embolism and passed away. The facility's failure to follow the resident's transfer protocol and the lack of immediate incident reporting and assessment contributed to the resident's injuries and subsequent death. Interviews with staff revealed a lack of awareness and adherence to the resident's transfer status. The LVN involved admitted to not realizing the resident required a hoyer lift and failed to report the incident immediately. The CNAs involved also did not verify the resident's transfer status before attempting the transfer. The facility's policies on hydraulic lift usage, fall prevention, and documentation were not followed, leading to the resident's fall and the subsequent failure to provide necessary medical assessment and documentation.
Failure to Document and Report Skin Changes
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not identify bruising and changes in skin condition for two residents, which could place them at risk of not receiving necessary medical care, harm, and hospitalization. Resident #1, an elderly man with severe cognitive impairment and thrombocytopenia, was observed with a dark purple blister on his right middle finger, which was not documented in his chart or skin assessments. Similarly, Resident #2, an elderly woman with severe cognitive impairment, was found with a bruise on her left wrist and a skin tear on her left arm, which were not documented in her chart or skin assessments. Interviews with staff revealed a lack of awareness and documentation regarding the residents' skin conditions. LVN D, who was responsible for Resident #1, was unaware of the blister and found no documentation in the resident's chart. Similarly, LVN D was also unaware of the bruise and bandage on Resident #2 and found no documentation regarding these issues. CNAs A, B, and C stated that they would report any changes in a resident's skin to a nurse immediately, but there was no evidence that this was done for the two residents in question. RN G and LVN E stated that they would document any changes in skin condition and notify the necessary parties, but this was not reflected in the residents' records. The facility's policies and procedures for documenting and reporting changes in residents' skin conditions were not followed. The Director of Nursing (DON) and the Administrator (ADM) stated that it was their expectation for staff to complete a skin assessment, notify the physician, and document any changes in the residents' clinical records. However, there was no evidence that these steps were taken for the two residents. The facility's failure to document and report changes in skin condition could lead to a lack of appropriate medical care and intervention for the affected residents.
Failure to Hold Blood Thinner Leads to Cancelled Dental Procedure
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care in accordance with professional standards of practice and the resident's care plan. The resident, who was on Eliquis, a blood thinner, was scheduled for a tooth extraction. However, the facility did not hold the medication as required, leading to the cancellation of the procedure. This oversight resulted in the resident experiencing ongoing pain and frustration due to the inability to proceed with the necessary dental work. The resident, who was cognitively intact and had a history of spastic quadriplegic cerebral palsy, epilepsy, bipolar disorder, and major depressive disorder, had requested dental services due to tooth pain. Despite being placed on antibiotics for a chronic abscess, the extraction could not be performed because the facility did not follow the recommendation to hold the blood thinner. The resident expressed significant discomfort and dissatisfaction with the facility's handling of the situation, feeling neglected and in pain. Interviews with facility staff revealed a breakdown in communication and procedure. The nurse practitioner had advised that the blood thinner should be held, but this was not communicated effectively or entered into the system as an order. The Director of Nursing acknowledged the lapse, noting that the recommendation to hold the medication was not converted into an actionable order. This failure in communication and procedure adherence led to the resident's continued pain and frustration.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents reviewed for falls. Resident #1, an elderly female with severe cognitive impairment and multiple risk factors for falls, fell and sustained a hip fracture requiring surgical intervention. Despite having a care plan with specific fall prevention interventions, the facility did not consistently implement these measures, as evidenced by the lack of completed fall risk assessments between incidents and the failure to ensure all interventions were in place at the time of the fall. Resident #1's care plan included various interventions such as keeping the bed in the lowest position, using a fall mat, ensuring the call light was within reach, and encouraging the use of non-skid footwear. However, on the day of the fall, the resident attempted to transfer herself from her wheelchair to her bed without assistance, resulting in a fall that caused a femoral fracture. The CNA who discovered the fall had previously assisted the resident to the toilet and reminded her to use the call button, but the resident did not call for help before attempting the transfer. Resident #2, who had a history of hemiplegia and muscle wasting, also had a care plan with fall prevention measures. However, the facility failed to complete the required fall risk assessments for this resident as well. The DON acknowledged that the new EMR system did not trigger quarterly fall risk assessments, leading to a gap in monitoring and updating care plans. This oversight contributed to the facility's failure to adequately supervise and prevent falls for both residents.
Failure to Timely Order Customized Manual Wheelchair
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASARR) federal requirements were met for a resident who required a customized manual wheelchair (CMWC). The resident, who has multiple diagnoses including Mild Cognitive Impairment, Intellectual Disability, and Peripheral Vascular Disease, was approved for a CMWC on 2/15/24. According to the Texas Administrative Code, the facility had five business days to order the wheelchair, with a deadline of 2/22/24. However, the wheelchair was not ordered until 2/26/24, after the facility received an email reminder from the PASRR team. This delay caused a postponement in the resident receiving her Medicaid Entitled Service. During an observation on 3/1/24, the resident was found lying in bed and mentioned that she was waiting for the wheelchair to get up. Interviews with the facility's administration revealed that they were aware of the delay and had taken steps to correct it on the same day they were notified by the state. The facility currently lacks a Minimum Data Set (MDS) nurse, and the Regional RN has been assisting with MDS needs. The delay in ordering the wheelchair placed the resident at risk of not achieving or maintaining her highest practicable level of physical functioning, as she was unable to participate in necessary therapies and mobility activities in a timely manner.
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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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