Focused Care At Linden
Inspection history, citations, penalties and survey trends for this long-term care facility in Linden, Texas.
- Location
- 1201 W Houston St, Linden, Texas 75563
- CMS Provider Number
- 675293
- Inspections on file
- 31
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Focused Care At Linden during CMS and state inspections, most recent first.
A resident with CVA, hemiplegia, bipolar disorder, moderate cognitive impairment, and wandering behaviors was assessed as high risk for elopement, but no intervention was immediately in place. He left the building unnoticed, was found outside near the road, and staff reported no alarm sounded before he was located. The nurse on duty stated she did not realize immediate intervention was required after the resident's risk status changed.
Missed PEG Medications and Supplements: The facility failed to provide ordered meds and supplements for two residents with significant neurologic and feeding-tube needs. MARs showed repeated missed doses of MVI, famotidine, Stress B-Complex, and GlycoLax because items were not available in the facility, and staff stated they did not notify the MD when the meds could not be given.
Unlocked Medication Cart and Medications Left Unsecured: An RN left a med cart unlocked and unattended while entering a resident's room and later the med room, and also left multiple med cards on top of the cart while preparing meds for a resident receiving several medications, including insulin, diuretics, antihypertensives, and diabetes meds. Interviews confirmed the cart should be locked when not in view and that meds should not be left on top of the cart.
Kitchen Equipment Not Kept Clean and Free of Buildup: Surveyors observed yellow to amber film buildup behind the [NAME], debris on a baking sheet, crumb debris in the toaster, and black carbon buildup on skillets stored next to the stove. Staff interviews confirmed the stove, fryer, toaster, and cookware were expected to be cleaned routinely, but acknowledged the buildup was still present and that the kitchen staff sometimes fell short on cleaning tasks. The facility policy required food prep areas and equipment to be cleaned and sanitized after use.
Failure to Protect Resident Privacy and Dignity During PEG Tube Care: An RN provided PEG tube meds and bolus feeding to a resident with CP, gastroparesis, PEG tube, and quadriplegia while the window blinds were left open to the parking lot and the resident’s abdomen was exposed. During the care, the RN also commented in front of the resident that his family was demanding and particular about his care and did not like too much water being used. The resident indicated the open blinds bothered him and that he preferred them closed.
Failure to Notify Resident Representative After Resident-to-Resident Incident: A resident with dementia and severe cognitive impairment was involved in a resident-to-resident altercation that caused a scratch to the right forearm. The progress note and incident report did not show that the RP was notified, and interviews confirmed the RP was not informed even though staff said family notification was expected for verbal or physical altercations.
Late Transmission of Discharge MDS Assessment: A resident with HTN and arthritis had a discharge MDS completed but not transmitted within the required timeframe. The MDS Coordinator said she was responsible for submitting MDSs and stated the delay was due to a software issue, while the Administrator said timely submission was expected under the facility policy and CMS guidelines.
Failure to care plan a resident’s pain needs. A resident with heart failure, morbid obesity, moderate memory impairment, substantial ADL assistance needs, and PRN tramadol use had no pain care plan in his comprehensive care plan, despite repeated pain medication administration and staff acknowledgment that pain should have been included with measurable interventions and timeframes.
Failure to post daily nurse staffing information was identified when the staffing pattern remained posted from a prior day instead of showing the current date, resident census, and actual hours worked. The DON stated the night nurse was responsible for updating the posting each day, and the Administrator stated the night nurse was responsible for ensuring it was posted daily, with the DON and weekend supervisor checking it. The facility policy required the shift supervisor to complete, date, and post the staffing form within 2 hours of the beginning of each shift.
A resident with multiple comorbidities experienced right knee pain and swelling, prompting a STAT x-ray order. Although the imaging was performed and results indicating fractures were available in the facility's portal, staff did not review or communicate the findings to the physician for four days, resulting in a delay in treatment. Staff interviews revealed unclear follow-up procedures and lack of timely handoff regarding pending diagnostic results.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, as evidenced by gaps in staff training and unclear guidance on reporting and prevention. This created an environment where such incidents could occur without prompt detection or intervention.
A resident with significant mobility and cognitive impairments was injured when an LVN provided incontinent care without ensuring the bed was locked, resulting in the bed rolling into a wall. The incident caused the resident to sustain fractures to the left foot and wrist, as well as bruising and abrasions. Facility staff confirmed the bed's brakes were mostly functional, and policies did not specifically require beds to be locked during care.
A resident with moderate cognitive impairment and a history of behavioral issues alleged that a staff member threw a blanket at her face and used inappropriate language. The allegation was reported to several staff members, including an LVN and a Social Worker, but was not reported to the Abuse Coordinator within the required timeframe, resulting in a delay of approximately three hours before the appropriate authority was notified, in violation of facility policy.
A resident with multiple medical conditions, including stage 3 pressure ulcers, was admitted to a facility without immediate wound care orders. The facility failed to initiate wound care treatment promptly, leading to a delay in care. Staff interviews revealed a lack of communication and understanding of procedures for obtaining and implementing wound care orders, and the resident was not provided with necessary pressure-relieving devices.
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their treatment and care. One resident did not receive timely wound care or a specialty mattress, and their weekly skin assessments were not performed. Another resident lacked documented wound care and weekly skin assessments, raising concerns about the care provided. A third resident also experienced similar issues, with the facility's staff failing to consistently follow through with wound care orders and documentation.
The facility failed to conduct annual competency evaluations for five RCPs, as required by policy. Personnel files lacked documentation of these evaluations, and interviews with the DON and Administrator revealed uncertainty about their completion. This oversight could affect the quality of care provided to residents.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with a history of falls and weight loss did not have these issues included in her care plan. Another resident's antiplatelet medication was not reflected in her care plan. Additionally, a resident requiring Enhanced Barrier Precautions did not have the necessary signage posted, indicating a lack of coordination in care planning.
The facility failed to provide adequate respiratory care for several residents, as evidenced by missing or dirty oxygen concentrator filters and improper storage of equipment. Residents with conditions such as cerebrovascular disease, heart failure, and COPD were affected. Staff interviews revealed confusion over responsibilities for maintaining oxygen equipment, leading to deficiencies in care.
Two residents in a LTC facility did not receive multiple essential medications due to failures in the pharmaceutical services. Medications for conditions like epilepsy, depression, and hypertension were unavailable on several occasions, as documented in the MAR. Staff interviews revealed issues with the medication ordering process, including delays in pharmacy delivery and communication problems. The facility's policy for timely medication ordering was not effectively followed, leading to these deficiencies.
A resident with severe mobility issues and cognitive impairment was repeatedly found with her call light out of reach, placed on her paralyzed side. Despite staff acknowledging the importance of keeping call lights accessible, the facility failed to ensure this accommodation, leading to potential delays in assistance and emotional distress for the resident.
A resident with a new diagnosis of Bipolar Disorder did not receive an updated PASRR, potentially affecting their access to necessary services. The facility's MDS Coordinator failed to complete the required documentation to reflect the resident's mental illness, as the previous MDS nurse did not update the necessary forms. This oversight was acknowledged by facility staff, who recognized the potential impact on the resident's care.
A resident with diagnoses of Major Depressive Disorder, Schizoaffective Disorder, and Bipolar Disorder was incorrectly marked as not having a mental illness on the PASRR Level 1 screening. The MDS Coordinator, responsible for completing PASRR evaluations, failed to ensure the assessment accurately reflected the resident's mental health status, as confirmed by the Director of Nurses. This oversight was contrary to the facility's PASRR policy, potentially impacting the resident's access to necessary services.
A resident admitted with multiple health issues did not receive a summary of their baseline care plan within 48 hours, as required. Staff interviews revealed confusion about responsibilities for completing and distributing the care plan. The facility's policy mandates completion and provision of the care plan summary within 48 hours, which was not followed.
A resident with multiple health issues did not receive necessary assistance with ADLs, including oral care and bed baths, since admission. Staff interviews revealed a lack of adherence to protocols, and the facility lacked a specific policy on ADL care, leading to oversight in providing essential services.
The facility failed to provide adequate supervision and safety for two residents. One resident, who was cognitively intact, had unauthorized rubbing alcohol in his room, posing a risk of accidental ingestion. Another resident, who was severely cognitively impaired, had exposed electrical wiring in his room, which was not reported or repaired as per facility policy. These lapses in supervision and safety measures could lead to potential harm.
The facility failed to provide proper catheter care and infection control for residents with urinary catheters, leading to potential risks of UTIs and other complications. A resident did not receive appropriate incontinent and catheter care, with improper hand hygiene and glove changes by staff. Two residents lacked securement devices for their catheters, increasing the risk of dislodgement and injury. Documentation of catheter care was also missing, indicating failures in monitoring and documentation processes.
A facility failed to maintain nutritional parameters for a resident with multiple health conditions, including Asperger's syndrome and epilepsy. The resident was not weighed weekly as required upon admission and readmission, and dietary recommendations to change health shakes were not followed. This led to a significant weight loss of 13.4% over 30 days. Staff interviews revealed a lack of clarity and coordination in responsibilities for weight monitoring and dietary interventions.
A facility failed to follow proper procedures before installing bed rails for a resident with multiple medical conditions, including Asperger's syndrome and epilepsy. The facility did not attempt alternatives, obtain informed consent, or conduct a bed rail assessment, posing a potential safety risk. Observations showed the resident had assist bars on both sides of her bed, but staff indicated she no longer needed them. The facility's policy required an interdisciplinary assessment and consent, which were not followed, leading to the deficiency.
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications, lacking adequate monitoring for antiplatelet use and side effect monitoring for anticonvulsants. One resident's records did not reflect necessary diagnoses for several medications, while another resident's records lacked appropriate diagnoses for Aricept and Aspirin. Staff interviews revealed deficiencies in monitoring and documentation procedures.
The facility failed to ensure adequate behavior and side effect monitoring for two residents prescribed psychotropic medications, including Sertraline, Buspirone, and Venlafaxine. This lack of documentation could hinder the assessment of medication effectiveness and safety. Interviews with staff highlighted the importance of monitoring, which was not consistently performed as per facility policy.
Two residents in a LTC facility experienced significant medication errors. A resident with GERD was not given Protonix before meals as required, affecting its effectiveness. Another resident with hypotension received Midodrine despite blood pressure readings exceeding prescribed parameters, risking hypertension. Staff interviews revealed non-compliance with physician orders and medication administration guidelines.
A resident's request for an alternate meal was not honored until a state surveyor intervened. The resident, who was cognitively intact and had a history of mental health disorders, had requested a deli sandwich instead of the spaghetti served. The Dietary Manager did not confirm the resident's meal preference and adhered strictly to the menu choices circled by residents, leading to dissatisfaction and potential negative outcomes. The facility's policy on accommodating food preferences was not followed, as residents were often restricted to their pre-selected menu items.
A facility failed to maintain effective infection control practices during incontinent and urinary catheter care for a resident with cognitive impairment and a history of infection. The RCP did not perform proper hand hygiene or glove changes, and placed a contaminated plastic bag on the resident's mattress. The resident had an indwelling catheter and pressure ulcers, increasing the risk of infection. Staff interviews revealed a lack of training and competency evaluations for the RCP.
The facility failed to obtain informed consent for psychoactive medications for three residents. One resident received Sertraline without a completed consent form, while another's consent for Seroquel lacked a written signature, and the resident was unaware of the medication's purpose. A third resident's consent for Zyprexa was incomplete, with no written signature. Staff interviews revealed confusion and inconsistencies in the consent process, risking uninformed administration of medications.
A resident with multiple medical conditions, including a deep tissue injury on the right heel, did not receive wound care as per physician's orders. The nurse applied Medihoney instead of betadine and wrapped the resident's foot incorrectly, contrary to the specified care plan. This failure to follow orders could lead to wound deterioration and infection.
A resident with an indwelling urinary catheter was found without a securement device, contrary to facility orders, increasing the risk of infection. During care, a CNA failed to change gloves after handling multiple items, further risking contamination. Interviews with staff confirmed these actions were against facility policies, highlighting deficiencies in catheter care and infection control.
A facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP). An RN did not wear protective equipment while completing wound care on a resident, and a CNA failed to change gloves and wear a gown during urinary catheter care for another resident. These actions risked cross-contamination and infection spread, as confirmed by facility leadership.
Failure to Supervise a High-Risk Resident at Risk for Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for a resident assessed to be at risk for elopement. Resident #20 was a male with diagnoses including CVA, hemiplegia, and bipolar disorder, and his quarterly MDS indicated a BIMS of 07, mobile with a walker, partial assistance with toileting, stand-by assistance for transfers and bed mobility, and wandering behaviors 1-3 days. An elopement risk assessment identified him as a moderate risk, and a later assessment identified him as a high risk with a score of 6 and noted that he voiced a desire to leave the facility. On 03/19/2026, the resident was last seen near the nurse's station attempting to call a family member and then heading back toward his room with his walker. About 15 minutes later, he was found outside the facility by the side of the road by an LPN returning from break. He had exited the building without staff knowledge or supervision and was located in the yard near the residential road adjacent to the facility. Staff interviews indicated no alarm sounded before he was found outside, and the nurse on duty stated she was not aware that she needed to immediately put an intervention in place after the resident was identified as high risk for elopement. The facility's record review showed that the resident had no elopement care plan in place before the incident, despite the change in risk status. The facility policy stated that when a resident triggers for high elopement risk, staff are to immediately notify the charge team and interdisciplinary team to review the care plan and implement necessary interventions. The deficiency was identified as Immediate Jeopardy and was based on the resident leaving the facility area without staff awareness or supervision after being assessed as high risk for elopement.
Missed PEG Medications and Supplements
Penalty
Summary
The facility failed to ensure that prescribed medications and supplements were accurately acquired, received, dispensed, and administered for 2 residents. For one resident with diagnoses including hypoglycemia, CVA, and convulsions, and who had severe cognitive impairment and required dependent assistance with ADLs, the record showed standing orders for Multivitamin with minerals, Pepcid 40 mg, and Stress B-Complex via PEG tube. The MAR documented multiple missed doses of all three items across March and April 2026. For that resident, the missed doses included Multivitamin with minerals on 3/24, 3/27, 3/28, 3/29, and 4/1 through 4/3; Pepcid on 3/26 through 3/29 and 4/1 through 4/3; and Stress B-Complex on 3/4 through 3/13 and 4/1 through 4/3. RN E stated she did not give the medications because they were not available in the facility, that she checked medication rooms and carts, and that she placed them on a reorder list. She also stated she did not think to call the MD to report that the medications were unavailable. For the second resident, who had cerebral palsy, gastroparesis, gastrostomy, quadriplegia, no speech, and was dependent on staff for all ADLs, the record showed orders for Multivitamin-minerals, famotidine, and GlycoLax via PEG tube. The MAR documented repeated missed doses of Multivitamin-minerals, famotidine, and GlycoLax in March and April 2026. During interviews, staff stated the facility had gaps in ordering OTC medications and supplies after the person responsible for ordering no longer worked there, that communication about low supplies was inconsistent, and that some items were not available in the building when needed. Staff also stated the MD was not notified when medications were unavailable, and the facility policy required medications to be administered in a safe and timely manner and in accordance with prescriber orders.
Unlocked Medication Cart and Medications Left Unsecured
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with professional standards for two residents and one medication cart. During an observation on 4/14/2026, RN E left the 100/300 hall medication cart unlocked and unsupervised when she went into Resident #27's room, which was two doors away from the cart. The cart was parked against the wall with the drawers facing the hallway at the time it was left unattended. During another observation, RN E prepared medications for Resident #8, including furosemide, carvedilol, hydralazine, glipizide, gabapentin, Jardiance, clonidine, and Lantus. After the surveyor recorded the medications, the medication cards were handed back to RN E and were left upside down on top of the medication cart. RN E later locked the cart to get another Lantus pen, but then left the cart again and returned with the cart unlocked while the seven medication cards remained on top of it. Later that day, RN E was observed sitting at the nurse's station while the medication cart was in front of her and not locked, and she went into the medication room for about five minutes, leaving the cart unlocked and unsupervised. Staff interviews confirmed the cart should be locked when not in the nurse's sight and that medications should not be left on top of the cart.
Kitchen Equipment Not Kept Clean and Free of Buildup
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen reviewed for food safety requirements. During an initial tour of the kitchen on 4/13/2026 at 9:08 AM, the Dietary Manager accompanied the surveyor and observed yellow to amber colored film buildup behind the [NAME] and along the right side of the [NAME], with a baking sheet screwed into the wall dividing the [NAME] from the oven. The baking sheet had a black area with debris and yellow substance scattered on it. The toaster was observed with crumb debris inside the toast area and debris in the base and corners, and four frying pans on the shelf next to the stove had black carbon buildup on the base, with one pan showing thick black buildup on the inside. On 4/14/2026 at 11:46 AM, black carbon buildup was again observed on pots and pans stored next to the stove. The [NAME] continued to have yellow to amber colored film buildup behind it and along the side, with the baking sheet still screwed to the wall. The skillets remained stored on the shelf next to the stove with black carbon buildup still present. During interviews on 4/15/2026, kitchen and administrative staff stated that the stove, toaster, fryer, and pots and pans were expected to be cleaned regularly, and several staff acknowledged that buildup on these items could cause a fire. The Director of Food Service stated the kitchen staff were responsible for cleaning the kitchen daily and that the deep [NAME] was cleaned every Friday, but also said the staff sometimes fell short on tasks and that the buildup on the fryer, stove, and skillets should not have been present. Record review showed the daily cleaning schedule for 4/13/2026 through 4/19/2026 assigned cooks to clean the oven, stove, and grill, with sign-offs completed on 4/13/2026 and 4/14/2026 by [NAME] G. The facility policy titled Kitchen Sanitation dated 3/2026 stated that equipment should be maintained in a clean, sanitary condition and free from spills, and that food preparation areas and equipment should be cleaned and sanitized after use. The observations and interviews showed that the kitchen equipment and surfaces were not maintained in that condition at the time of survey.
Failure to Protect Resident Privacy and Dignity During PEG Tube Care
Penalty
Summary
The facility failed to treat a resident with respect and dignity during PEG tube medication administration and bolus feeding. Resident #21 had cerebral palsy, gastroparesis, a gastrostomy/PEG tube, quadriplegia, no speech, and was dependent on staff for all ADLs. During an observation, RN E raised the resident’s shirt, exposing his bare abdomen and PEG tube, while setting up supplies and administering medications and tube feeding. The resident’s window blinds were left open during the care, and the window by his bed opened to the parking lot in front of the building. During the same care, RN E discussed the resident’s family in front of him, stating that his family was very demanding and particular about his care and that his family did not like it when staff used too much water. RN E continued making similar comments while flushing the PEG tube with water between medications and before and after the bolus feeding. After RN E left the room, the resident blinked once to indicate that it bothered him to have the blinds open during PEG tube care and that he would prefer the blinds to be closed. Facility leadership later stated the blinds should have been closed during PEG care and that staff should not discuss the resident’s family in the room.
Failure to Notify Resident Representative After Resident-to-Resident Incident
Penalty
Summary
The facility failed to notify the resident’s representative when Resident #50 had a resident-to-resident incident that resulted in a scratch to the right forearm. Resident #50’s record showed diagnoses including atherosclerotic heart disease, muscle wasting and atrophy, ataxia, dementia, and cognitive communication disorder. The quarterly MDS indicated he was severely cognitively impaired with a BIMS score of 3, and his care plan identified that he was involved in a resident-to-resident altercation and required monitoring for after effects and a skin assessment. A progress note documented that another resident grabbed Resident #50 by the collar while he was in the bathroom, grabbed his wrist, and forcefully pushed him to his bed, leaving a scratch measuring 4.5 cm x 0.3 cm x 0 cm on his right forearm. The note and incident report did not indicate that the RP was notified. Interviews with the RP, Resident #50, RN E, the DCO, and the ADM confirmed the RP was not informed of the incident, although staff stated they expected family notification for verbal or physical altercations and documentation of such notification in the progress note or incident report. The facility did not have a policy for notification of the resident representative.
Late Transmission of Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident #10’s discharge MDS assessment was electronically completed and transmitted to the CMS system within 14 days after completion. Resident #10 was a male admitted to the facility with diagnoses including hypertension and arthritis, and his admission MDS showed a BIMS score of 14 with no cognitive impairment. The face sheet indicated that he was discharged on 11/01/2025, and record review on 04/15/2026 showed that no discharge MDS had been transmitted prior to survey intervention. During interview, the MDS Coordinator stated she was responsible for completing and submitting MDS assessments and acknowledged that Resident #10’s discharge assessment had been completed but not transmitted within 14 days of discharge. She said the corporate MDS coordinator monitors the assessments she completed and stated the assessment was not transmitted because of a software issue. The Administrator stated she expected the MDS Coordinator to follow the facility’s MDS Completion and Submission policy and said timely submission was important to ensure the facility was following CMS guidelines.
Failure to Care Plan Resident Pain Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #8 that included measurable objectives and timeframes to meet his medical, nursing, mental, and psychosocial needs. Resident #8 was a male admitted with diagnoses of heart failure, morbid obesity, and pain, and his quarterly MDS dated 01/21/2026 showed a BIMS of 12, indicating moderate memory impairment. He required substantial assistance with ADLs including transfer, dressing, and toileting, and he received opioid pain medication. Record review showed an order for Tramadol 50 mg every 8 hours as needed for pain, and the April 2026 MAR reflected that he was administered tramadol 8 times from 04/01/2026 to 04/15/2026 for pain. His comprehensive care plan dated 03/17/2026 did not include a care plan for pain. During interviews, the MDS Coordinator stated pain should have been care planned to ensure a full picture of his needs, and the DON stated major diagnoses, conditions, medications, and falls should be care planned with interventions to alert staff and provide instructions. The facility policy stated that a comprehensive person-centered care plan includes measurable objectives and timetables and is developed and implemented for each resident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information with the current date, resident census, and the number of staff actual hours worked at the beginning of each shift in a place readily accessible to residents and visitors for 2 of 3 days. On 04/14/2026 at 9:30 a.m., observation showed the posted daily nurse staffing pattern was from 04/13/2026. On 04/15/2026 at 10:45 a.m. and again at 2:00 p.m., observation showed the staffing pattern was still posted as 0413/2026 rather than being updated for the current day. During interview on 04/15/2026 at 2:45 p.m., the DON stated the night nurse was responsible for changing the staffing posting each day and that she would take over checking to ensure it was done. She stated the failure to change it each day was an oversight by the night nurses and that not posting the staffing numbers could give the public inaccurate information about staffing in the building. During interview on 04/15/2026 at 3:00 p.m., the Administrator stated it was the responsibility of the night nurse to ensure the staffing numbers were posted daily, with the DON checking during the week and the weekend supervisor checking on weekends. Record review of the policy titled "Posting Direct Care Daily Staffing Numbers" stated that within 2 hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff, complete the Nursing Staff Directly Responsible for Resident Care form, date the form, record the census, and post the staffing information in the location designated by the Administrator.
Delay in Obtaining and Reporting STAT X-ray Results
Penalty
Summary
The facility failed to provide or obtain radiology and other diagnostic services to meet the needs of a resident who required a STAT x-ray. The resident, an elderly female with multiple diagnoses including dementia, multiple sclerosis, and osteopenia, complained of right knee pain and swelling. A STAT x-ray was ordered by the nurse practitioner and performed the same day, with results indicating a nondisplaced lateral plateau fracture and a distal fibular fracture. However, the facility did not review or act upon the x-ray results until four days after the imaging was completed. During this period, the x-ray results were available in the facility's electronic portal, but staff did not access or communicate the findings to the physician in a timely manner. Interviews revealed that staff were unclear about the timeframes for STAT orders and did not consistently follow up on pending results. The Director of Nursing was out of town and assumed the radiology company had resolved a missing diagnosis code, but no further follow-up occurred until she personally checked the portal days later. The 24-hour report sheets and progress notes did not reflect ongoing monitoring or follow-up regarding the x-ray results or the resident's knee condition during this interval. The delay in reviewing and reporting the STAT x-ray results led to a delay in treatment for the resident's fractures. Staff interviews indicated a lack of clear communication and handoff regarding the pending diagnostic results, and the facility's policy required timely notification of results to the physician. The resident continued to experience pain, though it was managed with medication, and there was no documentation of complications during the delay.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and preventing such incidents. The absence of robust preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
Resident Injured Due to Unlocked Bed During Incontinent Care
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including chronic obstructive pulmonary disease, peripheral vascular disease, and an above-the-knee amputation, was injured during incontinent care. The resident, who had moderate cognitive impairment and required substantial assistance for mobility and hygiene, was being assisted by an LVN. During the care, the LVN raised the bed and attempted to roll the resident, but the bed was not properly locked. As a result, the bed rolled into the wall, causing the resident to strike the wall with her foot, head, and left hand. Following the incident, the resident sustained multiple injuries, including fractures to the second and third metatarsals of the left foot and a distal ulna fracture in the left wrist, as confirmed by X-rays and orthopedic evaluation. Additional injuries included bruising and abrasions to both hands, a skin tear to the left hand, and redness and bruising to the left side of the forehead. The resident and her family reported that the injuries were a direct result of the bed rolling during care, and the LVN acknowledged that he believed the bed was locked but it still moved when he leaned against it. Interviews with facility staff revealed that the bed had six brakes, with only one found to be loose, and no mechanical reason was identified for the bed's movement if the brakes were properly engaged. The facility's policies on bed safety and resident safety did not specifically address the requirement to lock beds during incontinent care. The incident led to the resident requiring two-person assistance for future care, but the deficiency was due to the failure to ensure the bed was locked and the environment was free from accident hazards during care.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were reported immediately or within the required two-hour timeframe for one resident. A resident with schizoaffective disorder, diabetes, and hypertension, who had a history of verbal aggression and moderate cognitive impairment, alleged that a staff member threw a blanket at her face and told her to "shut the hell up." The incident was reported by the resident to a restorative care partner (RCP), who then informed an LVN. The LVN subsequently reported the allegation to the Social Worker, but none of these staff members reported the incident directly to the Abuse Coordinator (EDO) as required by facility policy. Interviews and record reviews revealed that the LVN and Social Worker did not recognize the incident as an abuse allegation and failed to notify the Abuse Coordinator immediately. The LVN stated she did not report the incident to the EDO because the EDO was not present in the facility at the time, and instead reported it to the Social Worker. The Social Worker also did not report the allegation to the EDO, stating she misunderstood the nature of the report and did not realize it was an abuse allegation until later. The delay in reporting resulted in the Abuse Coordinator learning of the incident approximately three hours after the initial allegation was made to staff. Documentation confirmed that the facility's policy required all events involving allegations of abuse to be reported immediately or within two hours. The failure of multiple staff members to follow this policy led to a delay in the investigation and intervention. The resident involved was not injured and did not express fear of living in the facility, but the delay in reporting the allegation constituted a deficiency in the facility's abuse reporting procedures.
Failure to Provide Immediate Wound Care Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident had physician orders for immediate care upon admission, specifically regarding wound care treatment. The resident, a female with multiple medical conditions including acute kidney failure, urinary tract infection, morbid obesity, and stage 3 pressure ulcers, was admitted without appropriate wound care orders. Despite having multiple areas of shearing and pressure ulcers, the facility did not initiate wound care treatment until several days after admission, leading to a delay in care. Upon admission, the resident had several pressure ulcers, including on the right hip, right thigh, and left thigh, which were not addressed with immediate wound care orders. The facility's records indicated that the resident's wounds were not properly assessed or treated in a timely manner, and there was a lack of documentation regarding the initiation of wound care. The facility's staff, including the admitting nurse and other clinical staff, failed to obtain or implement necessary wound care orders, resulting in a lack of appropriate treatment for the resident's pressure ulcers. Interviews with facility staff revealed a lack of communication and understanding of the procedures for obtaining and implementing wound care orders. The admitting nurse did not receive a timely response from the nurse practitioner regarding wound care, and there was confusion among staff about the resident's wound care needs. Additionally, the facility did not provide the resident with a specialty mattress or pressure-relieving devices, further contributing to the inadequate care of the resident's pressure ulcers.
Removal Plan
- Resident #93 had wound care orders written.
- A weekly wound assessment was completed.
- A specialty mattress was placed on Resident #93's bed.
- Resident #93's heels were floated.
- Skin sweep completed to ensure all skin issues were identified and had current orders and interventions in place.
- Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders.
- If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult.
- All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted.
- Education will also include the completion of weekly skin assessments per schedule.
- All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift.
- Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor.
- Ad hoc QAPI meeting will be held with the Medical Director reviewing the policies and procedures for wound care.
- All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation by the Director of Clinical Education or designee.
- All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers.
- Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds.
- Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion.
- Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely.
- Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly.
- The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their treatment and care. One resident was admitted with multiple stage 3 pressure ulcers but did not receive timely wound care treatment or a specialty mattress as per the facility's policy. The resident's weekly skin assessments were not performed as scheduled, and the facility did not implement necessary interventions such as repositioning and offloading to prevent further skin breakdown. Another resident did not have documented wound care on several occasions, and their weekly skin assessments were also not recorded as required. This lack of documentation raises concerns about whether the necessary care was provided to prevent the deterioration of existing wounds or the development of new ones. A third resident also experienced a lack of documented wound care and weekly skin assessments. The facility's failure to adhere to professional standards of practice and its own policies for wound care and prevention placed residents at risk for further wound deterioration and development. The facility's staff did not consistently follow through with wound care orders, and there was a lack of communication and documentation regarding the residents' wound care needs.
Removal Plan
- Resident #93 had wound care orders written.
- A weekly wound assessment was completed.
- A specialty mattress was placed on Resident #93's bed.
- Resident #93's heels were floated.
- Skin sweep completed to ensure all skin issues were identified and had current orders and interventions in place.
- Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders.
- If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult.
- All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted.
- Education will also include the completion of weekly skin assessments per schedule.
- All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift.
- Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor.
- Ad hoc QAPI meeting will be held with the Medical Director reviewing the policies and procedures for wound care.
- All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation by the Director of Clinical Education or designee.
- All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers.
- Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds.
- Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion.
- Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely.
- Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly.
- The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months.
Failure to Conduct Annual Competency Evaluations for RCPs
Penalty
Summary
The facility failed to conduct annual competency evaluations for five Resident Care Providers (RCPs), identified as RCP L, RCP O, RCP U, RCP V, and RCP W. These evaluations are crucial to ensure that the RCPs are proficient in the care they provide to residents. The personnel file review revealed that none of these RCPs had a competency evaluation on file, despite their hire dates being over a year prior. This oversight was discovered during a record review conducted on February 12, 2025. Interviews with the Director of Nurses and the Administrator revealed a lack of awareness regarding the completion of these evaluations. The Director of Nurses admitted to not knowing if the evaluations had been completed and could not locate them, suggesting that the previous Director of Nurses might not have filed them properly. The Administrator also expressed uncertainty about the completion of the evaluations, although she believed they had been done. The facility's policy requires all nursing staff to meet specific competency requirements and participate in a competency-based staff development program, which was not adhered to in this case.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #1, who had a history of falls and a fracture prior to admission, experienced an actual fall and unplanned weight loss, yet these issues were not included in her care plan. Additionally, her risk of pressure ulcers, pain management, and use of antiplatelet medication were not addressed in her care plan, despite being triggered in her MDS assessment. Resident #11, who was on an antiplatelet medication, did not have this medication reflected in her care plan, even though it was part of her physician's orders and medication administration record. This oversight indicates a lack of coordination between the resident's medical needs and the care planning process, potentially impacting her overall care and well-being. Resident #15, who required Enhanced Barrier Precautions due to an indwelling catheter, did not have the necessary signage posted in her room as per her care plan intervention. This failure was observed over multiple days, and staff interviews revealed a lack of clarity regarding responsibility for care plan updates and implementation. The absence of the Enhanced Barrier Precaution sign could lead to inadequate infection control measures, posing a risk to the resident and others in the facility.
Inadequate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by observations, interviews, and record reviews. Resident #18's oxygen concentrator was missing a filter, and the air intake area was covered with gray fuzzy and hair-like particles. Despite an order to clean or change the oxygen concentrator filters every Sunday night shift, the documentation indicated that the task was completed, but observations showed otherwise. Resident #18, who had a history of cerebrovascular disease and moderate cognitive impairment, was observed multiple times without her oxygen, and the concentrator remained in a poor state. Resident #24's oxygen concentrator filter was also covered in gray fuzzy and hair-like particles, and there was no order to clean or change the filters. Despite the resident's use of oxygen therapy for heart failure and dementia, the facility did not ensure the equipment was maintained properly. Interviews with staff revealed a lack of awareness and responsibility for maintaining the oxygen concentrator filters, which placed the resident at risk for respiratory infections. Resident #22's oxygen concentrator filter had white fuzzy particles, and the resident was not on the ordered number of liters of oxygen. Additionally, the resident's nebulizer mask was not stored in a bag when not in use, increasing the risk of infection. The facility's documentation was inconsistent, with missing entries for oxygen use and medication administration. Resident #38's oxygen concentrator filter was also dirty, and the nasal cannula tubing was not stored properly. Interviews with staff highlighted confusion over responsibilities for maintaining the oxygen equipment, contributing to the deficiencies observed.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for two residents. Resident #1 did not receive several medications, including Atorvastatin, Cannabidiol, Lamotrigine, Sertraline, Minocycline, and Topiramate, on multiple occasions throughout January 2025. These medications were crucial for managing conditions such as hyperlipidemia, epilepsy, depression, and bacterial infections. The absence of these medications was documented in the Medication Administration Record (MAR) with a code indicating the need to see progress notes, which often cited awaiting pharmacy delivery or being on order. Resident #15 also experienced similar issues with medication availability. Medications such as Amiodarone, Aricept, Aspirin, Calcitriol, Cozaar, Lokelma, Carvedilol, Macrobid, and Miconazole were not administered on several dates due to them being on order or awaiting delivery. These medications were essential for managing conditions like abnormal heart rhythm, dementia, hypertension, hypocalcemia, and urinary tract infections. The MAR entries for these medications frequently indicated they were on order or awaiting pharmacy delivery, with some entries lacking documentation for the reason medications were not administered. Interviews with facility staff revealed systemic issues in the medication ordering process. The Licensed Vocational Nurse (LVN) and Assistant Director of Clinical Operations (ADCO) indicated that medications should be ordered well in advance, but there were delays due to various reasons, including pharmacy processing times and communication issues with family members responsible for certain prescriptions. Additionally, there were problems with the electronic ordering system and the pharmacy's operational hours, which contributed to the missed doses. The facility's policy required timely ordering and receiving of medications, but these procedures were not effectively followed, leading to the deficiencies observed.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for the resident's needs and preferences. The resident, who had severe morbid obesity, reduced mobility, and a history of cerebrovascular disease, was observed multiple times with the call light placed out of reach on her paralyzed left side. This placement made it impossible for her to use the call light to request assistance, as she had no use of her left side. Interviews with staff members, including RCPs and LVNs, revealed that it was the responsibility of all staff to ensure that call lights were within reach of residents, especially those who were dependent on staff for assistance. Staff acknowledged that the call light should not be placed on the resident's paralyzed side and that failing to ensure the call light was accessible could lead to the resident feeling upset, helpless, and frustrated. Despite this understanding, the call light was repeatedly found out of reach during observations. The facility's policy on bedrooms, which was provided upon request, did not address the specific need for call lights to be within reach of residents. Interviews with various staff members, including the EDO and DCO, confirmed that ensuring call lights were accessible was a shared responsibility among all staff members. The deficiency was identified through observations and interviews, highlighting a failure to accommodate the resident's needs adequately.
Failure to Update PASRR for Resident with New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a mental health disorder received an accurate Preadmission Screening and Resident Review (PASRR) following a new diagnosis of Bipolar Disorder. The resident, who was initially admitted to the facility with no evidence of mental illness, was diagnosed with Bipolar Disorder in May 2023. However, the facility did not update the resident's PASRR status to reflect this new diagnosis, which could have impacted the resident's access to necessary assessments and specialized services. Interviews and record reviews revealed that the MDS Coordinator, who was responsible for updating the PASRR, did not complete the necessary documentation to capture the new diagnosis. The previous MDS nurse had added the diagnosis of Bipolar Disorder but failed to update the Mental Illness/Dementia Resident Review or the PL1 form. This oversight was acknowledged by the facility's staff, including the ADCO and EDO, who recognized that the resident might have missed out on services they qualified for due to the lack of timely updates to the PASRR documentation.
Inaccurate PASRR Level I Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessment for a resident, which did not reflect the resident's mental health diagnoses. The resident, who was admitted to the facility with diagnoses of Major Depressive Disorder, Schizoaffective Disorder, and Bipolar Disorder, was incorrectly marked as not having a mental illness on the PASRR Level 1 screening. This discrepancy was identified during a review of the resident's records, which showed that the PASRR Level 1 screening did not align with the resident's documented mental health conditions. Interviews with facility staff, including the MDS Coordinator and the Director of Nurses, revealed that the responsibility for completing the PASRR evaluations accurately lies with the MDS Coordinator. The Director of Nurses acknowledged that the resident's mental health conditions should have qualified for a positive PASRR Level 1 evaluation. The facility's policy on PASRR, dated November 2023, outlines the procedures for obtaining and completing PASRRs, but the failure to adhere to these procedures resulted in the resident not being properly assessed for needed services.
Failure to Provide Baseline Care Plan Summary to Resident
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed and provided to a resident and/or their representative within 48 hours of admission. A resident, who was admitted with acute kidney failure, urinary tract infection, morbid obesity, and stage 3 pressure ulcers, did not receive a copy of the summary of the baseline care plan. The resident reported that a staff member began the baseline care plan upon admission but did not complete it due to being busy, and no one returned to finish it. The resident expressed a desire to have a copy of the care plan, which was not provided. Interviews with various staff members revealed confusion and lack of clarity regarding the responsibility for completing and distributing the baseline care plan. The ADCO mentioned that the admitting nurse could start the care plan, but it was unclear who was responsible for providing the summary to the resident. The EDO and DCO from a sister facility also provided conflicting information about the process and responsibilities. The facility's policy stated that the baseline care plan must be completed within 48 hours and a summary provided to the resident, but this was not adhered to in this case.
Failure to Provide ADL Care for Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident, specifically in the areas of oral care and bed baths. Resident #93, a female with acute kidney failure, urinary tract infection, morbid obesity, and stage 3 pressure ulcers, did not receive oral care or bed baths as required. Despite being admitted to the facility less than 21 days ago, the resident reported not receiving any bed baths or oral care since her admission. Observations confirmed that the resident's personal hygiene items, including a toothbrush and wash basin, appeared unused. Interviews with staff revealed a lack of adherence to the facility's protocols for providing ADL care. Licensed Vocational Nurse (LVN) D and Resident Care Provider (RCP) H acknowledged that the resident required moderate to extensive assistance with bathing and oral care, yet these services were not provided. RCP H admitted to not offering oral care or bed baths to the resident and was unsure of the frequency of hair washing required for the resident. The Director of Clinical Operations (DCO) and other staff members confirmed that oral care should be provided every shift and bed baths should occur three times a week, but these standards were not met for Resident #93. The facility lacked a specific policy on ADL care related to bathing and oral care, contributing to the oversight in providing necessary services to Resident #93. Staff interviews highlighted the importance of ADL care for maintaining hygiene, preventing infections, and ensuring residents' dignity and quality of life. The failure to provide these services could lead to poor hygiene, skin breakdown, and a negative impact on the resident's well-being.
Inadequate Supervision and Safety Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for two residents, leading to potential risks. One resident, who was cognitively intact, was found with a bottle of isopropyl 91% rubbing alcohol in his room, which he used on his skin. The resident was unaware of how he obtained the alcohol. Facility policy prohibits residents from keeping rubbing alcohol in their rooms due to the risk of accidental ingestion and poisoning. Interviews with staff confirmed that residents should not have access to rubbing alcohol, and it was against facility policy. Another resident, who was severely cognitively impaired, had exposed electrical wiring in his room. The resident was dependent on assistance for activities of daily living due to his medical conditions, including bipolar disorder and chronic inflammatory demyelinating polyneuritis. Staff interviews revealed that exposed wiring should be reported and repaired to prevent potential harm. The facility's policy requires incidents and accidents to be investigated and reported, but the presence of exposed wiring indicates a lapse in adherence to these safety protocols.
Inadequate Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, leading to potential risks of urinary tract infections (UTIs) and other complications. Resident #10, who had a history of cognitive impairment and was dependent on staff for toileting hygiene, did not receive proper incontinent and urinary catheter care. During an observation, RCP O did not perform hand hygiene or change gloves appropriately while providing care, and failed to clean the resident's perineum area or urinary catheter insertion site effectively. The plastic bag used for soiled washcloths was repeatedly placed on the resident's bed after falling on the floor, posing an infection control issue. Interviews with staff revealed a lack of competency evaluations and training for RCP O, contributing to the improper care provided. Resident #15, who had an indwelling catheter due to neurogenic bladder, was found without a securement device for the catheter on multiple occasions. The absence of a securement device increased the risk of catheter dislodgement and potential injury. Despite physician orders and care plans indicating the need for securement devices, observations and interviews confirmed that the resident did not have the device in place, and staff failed to ensure its use. The lack of securement was not documented, indicating a failure in the facility's monitoring and documentation processes. Resident #22 also experienced inadequate catheter care, with missing documentation of catheter care on several dates. The resident reported that catheter care was not provided daily, and observations showed cloudy urine, suggesting potential infection. The securement device for the catheter was not in place, as confirmed by the resident and staff interviews. The facility's policies on catheter care and hand hygiene were not followed, leading to increased risks of infection and discomfort for the residents involved.
Failure to Maintain Nutritional Parameters and Monitor Weight
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to a deficiency in care. The resident, who had a history of Asperger's syndrome, epilepsy, a displaced bimalleolar fracture, and osteoarthritis, was not weighed weekly as required upon admission and readmission. The facility did not obtain the resident's weight after her readmission from a hospital stay, which was crucial for establishing a new baseline. Additionally, the facility did not follow the dietary recommendation to change the resident's health shakes to house shakes for 90 days, which was intended to address weight concerns. The resident's medical records indicated a significant weight loss of 13.4% over 30 days, yet the facility's care plan did not reflect this unplanned weight loss. The facility's failure to document and monitor the resident's weight as per the established guidelines and dietary recommendations contributed to the deficiency. Interviews with facility staff revealed a lack of clarity and coordination regarding responsibilities for obtaining and documenting weights and implementing dietary recommendations. The facility's Weight Surveillance Program policy required weekly weights for new admissions and readmissions, but this was not adhered to in the resident's case. Staff interviews highlighted that the dietary recommendations were not accurately transcribed or followed, which could have helped in addressing the resident's weight loss. The deficiency was further compounded by the absence of a clear assignment of responsibilities among the staff for monitoring and implementing dietary interventions.
Failure to Follow Bed Rail Protocols for Resident
Penalty
Summary
The facility failed to adhere to proper procedures before installing bed rails for a resident, leading to a deficiency. The resident, a female with a history of Asperger's syndrome, epilepsy, a displaced bimalleolar fracture, and osteoarthritis, was admitted to the facility and required supervision and assistance for various mobility tasks. Despite these needs, the facility did not attempt alternative measures before installing bed rails, nor did they obtain informed consent from the resident or her representative prior to installation. Additionally, the facility did not conduct a bed rail assessment to evaluate the risk of entrapment for the resident. Observations revealed that the resident had assist bars on both sides of her bed, which she sometimes used for repositioning. However, interviews with staff indicated that the resident no longer needed the assist rails, as she refused to get out of bed and had limited safety awareness. The lack of a proper assessment and informed consent posed a potential safety risk to the resident. The facility's policy required an interdisciplinary assessment and consultation with the attending physician before using side rails, as well as obtaining consent from the resident or their legal representative. However, these steps were not followed, and the resident's care plan and medical records did not reflect the use of assist rails or an assessment for entrapment risk. Interviews with various staff members highlighted inconsistencies in the process of ordering, assessing, and maintaining bed rails, contributing to the deficiency.
Failure to Monitor and Document Medication Use
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary medications. Specifically, the facility did not provide adequate monitoring for the use of antiplatelet medications for both residents. Additionally, one resident did not have side effect monitoring for anticonvulsant use, and there were no documented diagnoses for several medications prescribed to this resident, including Lamotrigine, Levothyroxine, Minocycline, Ondansetron, Sertraline, and Topiramate. For the first resident, the facility's records did not reflect the necessary diagnoses for the prescribed medications, nor did they include monitoring for the use of an antiplatelet or side effect monitoring for anticonvulsant use. This resident had a history of epilepsy, major depressive disorder, anxiety disorder, and hypothyroidism, and was receiving multiple medications without proper documentation or monitoring. The second resident's records also lacked appropriate diagnoses for medications such as Aricept and Aspirin. The facility did not ensure monitoring for the use of an anticoagulant, and the resident's care plan did not reflect the use of an antiplatelet. Interviews with facility staff revealed a lack of understanding and implementation of proper monitoring and documentation procedures for these medications.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Resident #1, a female with diagnoses including Asperger's syndrome, epilepsy, major depressive disorder, and anxiety disorder, was prescribed Sertraline, an antidepressant. However, there was no documentation of behavior and side effect monitoring for this medication, which is crucial for assessing the medication's effectiveness and safety. Similarly, Resident #11, a female with diagnoses including cerebral infarction, type 2 diabetes, depression, and anxiety disorder, was prescribed Buspirone for anxiety and Venlafaxine for depression. The facility did not document behavior monitoring for these medications, which is necessary to justify their use and ensure they are achieving the desired therapeutic outcomes without adverse effects. Interviews with facility staff, including an LVN, the ADCO, and the EDO, revealed that behavior and side effect monitoring should be documented on each shift for residents on psychotropic medications. The lack of such documentation could prevent the identification and treatment of side effects or ineffective medication use. The facility's policy emphasizes the importance of monitoring psychotropic drug use and conducting regular reviews to assess the necessity and appropriateness of these medications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #1, who has a history of Asperger's syndrome, muscle weakness, and constipation, was prescribed Protonix for GERD. The medication was not scheduled to be administered before meals as required for optimal effectiveness. Instead, it was given at 9 a.m., which is not ideal for the medication's intended therapeutic effect. Observations noted that Resident #1 did not respond to greetings, and attempts to contact her responsible party were unsuccessful. Resident #93, who was admitted with acute kidney failure and hypotension, was prescribed Midodrine to treat low blood pressure. The medication was to be held if the resident's blood pressure exceeded certain parameters and was to be administered with meals. However, the medication was given even when the resident's blood pressure was above the ordered parameters on multiple occasions. Interviews with staff revealed a lack of adherence to the physician's orders, with the medication being administered outside the specified conditions, potentially placing the resident at risk for hypertension or stroke. Interviews with various staff members, including LVNs and the ADCO, highlighted a lack of compliance with medication administration guidelines. Staff acknowledged the errors and the importance of following physician orders, including the timing of medication administration and adherence to hold parameters. The facility's policy on medication administration emphasizes the need for medications to be given as prescribed, yet these guidelines were not followed, leading to the deficiencies noted in the report.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, specifically for Resident #17, who was cognitively intact and had a history of bipolar disorder, major depressive disorder, and anxiety disorder. On the date in question, Resident #17 had requested an alternate meal choice for lunch, which was not honored until a state surveyor intervened. The resident had circled only vegetables and dessert on her menu and had verbally requested a deli sandwich, which was not communicated to the dietary staff. The Dietary Manager did not confirm with the resident if she had accidentally omitted a main meal item and instead served her spaghetti, which she did not like. Interviews revealed that the Dietary Manager typically adhered strictly to the menu choices circled by residents and did not accommodate changes unless there was time and food available. The Dietary Manager's approach was perceived as inflexible by both the resident and staff, with the Dietary Manager reportedly acting as if the food budget was her personal expense. This rigidity in accommodating food preferences was highlighted by a previous incident where the resident was initially denied oatmeal, which she had not marked on her menu but later received after some delay. The facility's policy on resident food preferences indicates that individual preferences should be assessed and accommodated, with a variety of foods offered at each meal. However, the Dietary Manager's actions did not align with this policy, as residents were often restricted to their pre-selected menu items. This failure to honor food preferences could potentially lead to decreased food intake and other negative outcomes for residents, as noted by the ADCO and DCO during their interviews.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper hand hygiene and glove use by a Resident Care Provider (RCP) while providing incontinent and urinary catheter care to a resident. The RCP did not perform hand hygiene after changing gloves and failed to clean the resident's perineum area or urinary catheter insertion site properly. This lack of proper hygiene practices could lead to cross-contamination and increase the risk of infection for the resident. The resident involved had a history of infection, cognitive impairment, and was dependent on staff for toileting hygiene. She had an indwelling urinary catheter and was always incontinent of bowel, with a stage 3 pressure ulcer and moisture-associated skin damage. During the care process, the RCP placed a plastic bag on the resident's low air loss mattress, which fell onto the floor multiple times. The RCP picked up the bag and placed it back on the mattress without changing gloves or performing hand hygiene, further compromising the resident's environment. Interviews with facility staff revealed that the RCP had not received proper training or competency evaluations for incontinent and urinary catheter care. The Director of Resident Accounts and other staff members acknowledged the infection control issues and the lack of proper training and documentation. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, contributing to the deficiency in infection control practices.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the administration of psychoactive medications. For one resident, the facility did not complete the psychoactive medication therapy consent upon admission and prior to administering Sertraline, an antidepressant. Despite the medication being prescribed and administered, there was no record of a consent form, and the facility staff could not locate it. Interviews with staff revealed a lack of clarity on who was responsible for obtaining the consent, and it was acknowledged that the absence of consent placed the resident and their family at risk of not being informed about the medication's risks and benefits. Another resident's consent for antipsychotic medication, Seroquel, was not properly documented. The consent form lacked a written signature, and the resident reported not being informed about the medication's purpose or side effects. The resident expressed uncertainty about the medication's use and did not recall giving verbal consent. Staff interviews indicated that verbal consent was noted without proper documentation, and there was confusion about the process for obtaining and recording consent. A third resident's consent for Zyprexa, another antipsychotic medication, was also incomplete, with no written signature from the resident or their representative. The resident was unwilling to discuss their medication, and attempts to contact their representative were unsuccessful. Staff interviews highlighted inconsistencies in the process of obtaining consent, with some staff unsure of the requirements and others acknowledging the importance of informed consent to ensure residents and their representatives understood the medication's risks and benefits. The facility's policies and state regulations emphasize the necessity of informed consent, which was not adhered to in these cases.
Deficiency in Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in wound management. The resident, who had multiple medical conditions including diabetes, peripheral vascular disease, and pressure-induced deep tissue injury (DTI) on the right heel, did not receive wound care as per the physician's orders. The orders specified that the right heel should be cleansed with normal saline, patted dry, and painted with betadine, but instead, Medihoney was applied, which was not suitable for the condition of the wound. The nurse responsible for the wound care, RN E, had only been working at the facility for two weeks and was not familiar with the residents. During an observation, RN E was seen applying Medihoney to the right heel instead of betadine, and wrapping the resident's right foot with gauze and elastic wrap incorrectly. This was contrary to the physician's orders, which required the right heel to be left open to air and the legs to be wrapped from the base of the toes to below the knees, avoiding pressure on the DTI. Interviews with the nurse practitioner, assistant director of nursing, and director of nursing confirmed that the incorrect application of Medihoney and improper wrapping could lead to the deterioration of the wound. The facility's policy on skin management emphasized the importance of following physician's orders to prevent and treat skin breakdown, but these were not adhered to, resulting in a risk of infection and impeded healing for the resident.
Failure in Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care for a resident with urinary incontinence, specifically in the management of an indwelling urinary catheter. The resident, who was cognitively intact and required maximal assistance for toileting hygiene, had an indwelling catheter and was at risk for urinary tract infections due to obstructive uropathy. Despite having an order to ensure the catheter was secured to reduce friction and pulling, the resident was found without a catheter securement device during care, which was confirmed by the CNA providing care. During the provision of incontinent and catheter care, CNA A did not perform hand hygiene or change gloves appropriately, which could lead to contamination and increased risk of infection. CNA A handled multiple items in the resident's room before performing catheter care without changing gloves, which was acknowledged as a risk for spreading germs and causing infection. The CNA admitted to not changing gloves and recognized the increased risk of infection due to this oversight. Interviews with facility staff, including the ADON and DON, confirmed that the lack of a catheter securement device and improper glove use during catheter care were against facility policies and placed the resident at risk of infection. The DON acknowledged that the nurse should not have documented the presence of a securement device without visual confirmation. The facility's policies and CDC guidelines emphasize the importance of securing catheters and maintaining hygiene to prevent infections, which were not adhered to in this case.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN E and CNA D, which did not adhere to the Enhanced Barrier Precautions (EBP) policy. RN E did not follow the EBP policy while performing wound care on a resident with a pressure ulcer on the right heel. After applying an adhesive dressing, RN E removed her gown and gloves and continued to wrap the resident's foot with gauze and an elastic wrap without wearing protective equipment, potentially risking the spread of infection. RN E admitted to not being fully informed about the EBP requirements and acknowledged the mistake during an interview. CNA D also failed to adhere to the EBP policy while providing urinary catheter care to another resident. CNA D did not wear a gown and failed to change gloves after cleaning the resident's catheter, subsequently touching various items in the resident's room, including the catheter securement device, bedding, and catheter drainage bag. This oversight was acknowledged by CNA D, who admitted to forgetting the proper procedure and recognized the risk of cross-contamination and infection spread. Interviews with the facility's ADON, DON, and ADM confirmed that both RN E and CNA D did not follow the facility's infection control policies. The ADON and DON highlighted the importance of using gowns and gloves during high-contact care activities to prevent the spread of infection. The ADM emphasized the expectation for staff to adhere to infection control policies and acknowledged the potential risk of infection due to the staff's failure to follow the EBP guidelines.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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