Frank M. Tejeda Texas State Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Floresville, Texas.
- Location
- 200 Veterans Dr, Floresville, Texas 78114
- CMS Provider Number
- 675863
- Inspections on file
- 42
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Frank M. Tejeda Texas State Veterans Home during CMS and state inspections, most recent first.
Two residents reported financial concerns that were not timely reported as alleged violations to the administrator and State Survey Agency as required. One resident with intact cognition and dementia-related diagnoses filed a grievance after learning from her daughter that her credit card had been charged for a grocery curbside order she did not make; a staff member later admitted using the resident’s stored card information on a personal phone for a personal purchase while the resident was hospitalized. Another cognitively intact resident reported $57 missing from a locked drawer, stating the key had been kept in a visible, unlocked drawer. In both cases, the concerns were documented as grievances, but the social worker and administrator did not treat them as reportable allegations of misappropriation or theft under facility policy and regulatory requirements, and they were not reported to state authorities within mandated timeframes.
Two residents reported financial and property concerns that were not treated as reportable abuse-related allegations. One resident with DM2 and dementia, but intact BIMS, filed a grievance after learning her credit card had been charged for a grocery curbside order she did not make; a staff member later documented that the resident’s saved card was used in error for the staff member’s personal order. Another cognitively intact resident reported $57 missing from a locked drawer, with the key kept visibly in an unlocked drawer; a SW documented that the drawer was intact and no money was found. The DON and Administrator acknowledged that these grievances were not reported to the State Survey Agency and were not investigated as alleged violations, despite facility policies requiring prompt reporting and investigation of suspected misappropriation and theft of resident property.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to maintain effective infection control practices for three residents. A resident was not placed under contact precautions as ordered, and improper glove use was observed during wound care. Another resident's medication administration involved cross-contamination risks due to improper handling of a water cup. Additionally, a resident self-administering eye drops was not instructed to sanitize hands, leading to potential infection spread.
A resident's annual MDS assessment failed to accurately reflect their tobacco use, despite their care plan indicating smokeless tobacco use and observations by staff. The responsible RN acknowledged the oversight, attributing it to the resident's past use of a vape cigarette. The facility uses the RAI manual for MDS updates, which was not followed correctly in this case.
A facility failed to update a resident's care plan to accurately reflect their current tobacco use, which stated the resident smoked and used a vapor cigarette, while they had quit smoking and only used dip tobacco. The resident was cognitively intact, and the oversight was acknowledged by the DON and RN responsible for care plan updates.
A resident with multiple health conditions, including diabetes and chronic kidney disease, did not receive proper incontinent care, leading to a deficiency in preventing urinary tract infections. CNAs failed to clean the resident's urinary meatus and did not re-clean after the resident urinated, contrary to facility policy. The DON confirmed the oversight, highlighting a lapse in following infection control protocols.
A facility failed to label a bottle of Ciprofloxacin 0.3% ophthalmological solution with an open date, as required by professional principles. This medication, prescribed for a resident with chronic allergic conjunctivitis, was observed without the necessary labeling, which was confirmed by a Medication Aide. The DON stated that medications should be labeled with open dates to ensure they are not used beyond their effective period.
Failure to Timely Report Alleged Misappropriation and Theft of Resident Property
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, misappropriation, or mistreatment, including injuries of unknown source, were reported within required timeframes to the administrator and appropriate state officials. For one resident, an unauthorized use of a credit card by a staff member for a personal purchase was not identified or treated by the administrator as an alleged violation of misappropriation of funds, despite being brought forward through the grievance process. For a second resident, an allegation of missing money from a locked drawer was not reported by the social worker to the administrator as an alleged theft or misappropriation, and the administrator did not report the allegation to the State Survey Agency within 24 hours as required. Resident #1 was an older female with type 2 diabetes mellitus, unspecified dementia, and a cognitive communication deficit, but with a BIMS score of 14 indicating intact cognition and no documented memory concerns. She was dependent on staff for toileting hygiene but independent in other ADLs. She was sent to the ER on 02/28/2026 and admitted with Flu A, returning to the facility on 03/02/2026. On 03/06/2026, she submitted a grievance stating that her daughter had informed her that her credit card had been charged for $152 at a grocery store curbside service, and that she had not made a purchase that day. The grievance was received by the Social Services Director. Subsequent documentation showed that the Health Information Manager admitted using the resident’s credit card "in error" for a personal curbside order because the resident’s card information had been stored in the staff member’s personal phone wallet from prior food orders placed for the resident. The Health Information Manager’s written statement confirmed that the resident’s credit card had been used on 02/28/2026 for a personal grocery order while the resident was in the hospital, and that the staff member contacted the responsible party and arranged reimbursement. The DON acknowledged being notified of the grievance and that the staff member had used the resident’s credit card without authorization, and also acknowledged that the incident was not reported to the State, though she stated it perhaps should have been. The administrator stated she was aware of the grievance, reviewed it, and knew that the staff member had used the resident’s credit card stored on a personal cell phone for a personal purchase, but she did not consider it an alleged violation requiring reporting because she believed it was unintentional and did not rise to that level. No employee coaching record related to this incident was provided upon request. Resident #2 was an older male with atherosclerotic heart disease, a history of transient ischemic attack, and seizures, with a BIMS score of 13 indicating intact cognition and no documented memory concerns, and was independent in self-care and mobility. He submitted a grievance reporting that $57 was missing from a locked drawer in his room, stating that he remembered the drawer being locked and that the key was kept in another, unlocked drawer with his socks where it was visible. The social worker documented examining the drawer, finding it intact and not openable without a key, and confirmed that no money was found. The resident was educated on key use, his right to keep the key on his person, to maintain a spending log, and his right to file a police report, which he declined at that time. The administrator later acknowledged being aware of this grievance of missing money but stated that it was not brought to her as an allegation of theft and that she did not view it as a specific allegation requiring reporting to the State Agency. She described that many male residents loan money to others and was unsure whether the missing money grievance was confirmed. The DON reported she had not been notified of this grievance and would need to follow up with the social worker. Facility policies on abuse, misappropriation, and grievances stated that all alleged or suspected violations, including theft or misappropriation of resident property, must be promptly reported to community management and appropriate state agencies, and that residents have the right to be free from abuse and exploitation and to keep personal property secure from theft or loss. Despite these policies, the allegations involving unauthorized use of a resident’s credit card and missing resident funds were not treated and reported as required alleged violations. The facility’s written guidance defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, and defined an alleged violation as any observed or reported situation that, if verified, could be noncompliance with federal requirements related to mistreatment, exploitation, neglect, abuse, or misappropriation. The same guidance required that all alleged or suspected violations and all substantiated incidents of abuse be promptly reported to appropriate state agencies. Nonetheless, the administrator and social worker did not report the two residents’ allegations of unauthorized credit card use and missing money to the State Survey Agency within the required timeframes, resulting in the cited deficiency for failure to timely report suspected abuse, neglect, exploitation, or misappropriation.
Failure to Investigate and Report Alleged Misappropriation and Theft of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report alleged violations of abuse, neglect, and exploitation, specifically misappropriation of funds and theft of property, for two residents. For the first resident, an older female with type 2 diabetes mellitus, unspecified dementia, and a cognitive communication deficit, the quarterly MDS showed a BIMS score of 14, indicating intact cognition without noted memory concerns. Her care plan documented impaired cognitive function/dementia or impaired thought process, and she was dependent on staff for toileting hygiene but independent in eating, showering, and mobility. A grievance form dated 03/06/2026 documented that this resident reported her daughter had informed her that the resident’s credit card was charged $152.00 at a grocery store curbside service, and the resident stated she had not made a purchase on that date. The grievance noted that the resident still had the credit card in her wallet and that her daughter was canceling the card. Further documentation for this resident included a written statement dated 03/10/2026 from the Health Information Manager, who reported that on 02/28/2026 she placed a curbside grocery order and, in error, used the resident’s credit card that had been previously saved in her phone wallet after prior authorized purchases for the resident. She acknowledged that this error resulted in a $152.42 charge to the resident’s card, described contacting the responsible party, and described arrangements to reimburse the funds. The Director of Nursing later stated in interview that she recalled the grievance about unauthorized use of the credit card but did not report it to the State Survey Agency or conduct an investigation because she viewed it as an unintentional occurrence. The Administrator, who served as the Abuse and Neglect Coordinator, similarly stated that she did not consider the incident to rise to the level of an alleged violation, did not report it to the State Survey Agency, and did not investigate further. For the second resident, an older male with atherosclerotic heart disease, a history of transient ischemic attack, and seizures, the quarterly MDS showed a BIMS score of 13, indicating intact cognition and organized thinking, and he was documented as independent in self-care and mobility. His care plan indicated he was able to participate in activities of his choice within his physical and cognitive abilities. A grievance form dated 03/13/2026 documented that this resident reported $57 missing from a locked drawer in his room, stating he remembered the drawer being locked and that the key was kept in another, unlocked drawer with his socks where it was visible. The social worker documented examining the drawer, noting it was not broken and could not be opened without a key, and that the key was visible in the other drawer; no money was found. The grievance response included education to the resident about key use, his right to keep the key on his person, to maintain a spending log, and his right to file a police report, which he declined at that time. The DON stated she was not notified of this grievance and was unaware whether the incident was investigated further by the Administrator. The Administrator stated that the grievance was handled by the social worker, that she was not familiar with the details, and that she did not view all grievances involving money as reportable allegations, so she did not report or investigate this matter as an official allegation. Facility documents, including the Code of Conduct, Grievances policy, Statement of Resident Rights, and Abuse Guidance, described expectations that staff respect resident rights, not take resident property, and immediately report any suspected abuse, neglect, or theft of resident property to supervisors and community management. The Abuse Guidance defined misappropriation of resident property as wrongful use of a resident’s belongings or money without consent and defined an alleged violation as any reported situation that, if verified, could be noncompliance with federal requirements related to mistreatment, exploitation, neglect, abuse, or misappropriation of resident property. The same guidance stated that all alleged or suspected violations and all substantiated incidents of abuse would be promptly reported to appropriate state agencies per state and federal requirements. Despite these written policies, the facility did not treat the unauthorized use of the first resident’s credit card or the second resident’s report of missing funds from a locked drawer as alleged violations requiring investigation and reporting to the State Survey Agency, resulting in the cited deficiency.
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 protective measures and oversight.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident #23, the facility did not implement contact precautions as ordered by the physician. Despite the presence of a contact isolation sign, Resident #23 was observed in the day room with other residents, indicating a failure in communication and implementation of isolation protocols. Additionally, during wound care, LVN D did not change gloves or sanitize hands after cleansing the wound, which could lead to the spread of infection. For Resident #90, improper infection control practices were observed during medication administration. MA G was seen handling a cup of water with her fingers inside the cup, which could result in cross-contamination. Despite being trained in infection control, MA G admitted to forgetting the proper procedure while managing multiple tasks simultaneously. Resident #135's supervised self-medication administration of eye drops also demonstrated lapses in infection control. MA C did not instruct the resident to sanitize hands before applying the eye drops and failed to observe the resident's technique, which included wiping excess medication with soiled hands. This oversight could lead to cross-contamination and further infection, as the resident's hands were not cleaned before or after the procedure.
Inaccurate Tobacco Use Assessment for Resident
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for one resident whose assessments were reviewed. Specifically, the resident's use of tobacco was not identified on the resident's annual Minimum Data Set (MDS) assessment. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had a comprehensive care plan indicating the use of smokeless tobacco. However, the MDS assessment incorrectly coded the resident as not using tobacco, which was an oversight by the responsible RN. This error occurred despite the resident's care plan clearly stating the use of smokeless tobacco and the resident being observed using it in the facility's smoking area. The RN responsible for completing the MDS acknowledged the error, attributing it to the resident's previous use of a vape cigarette, which had been discontinued two years prior. The Director of Nursing (DON) was unaware of the discrepancy in the annual assessment, although she had observed the resident using smokeless tobacco. The facility utilized the Resident Assessment Instrument (RAI) manual for MDS and care plan updates, which was available to staff digitally. The coding instructions in the RAI manual specify that any form of tobacco use during the look-back period should be coded as 'yes,' indicating a failure to adhere to these guidelines in this instance.
Failure to Update Resident's Care Plan for Tobacco Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's mental, nursing, and psychosocial needs. Specifically, the facility did not update the care plan to accurately reflect the resident's current tobacco use. The resident, who was cognitively intact with a BIMS score of 15, had a care plan that incorrectly stated they smoked tobacco and used a vapor cigarette, while in reality, they had quit smoking and only used dip tobacco. The Director of Nursing (DON) acknowledged that the care plan should have been updated to reflect the resident's current use of smokeless tobacco. The MDS LVN, responsible for updating care plans, missed this change. The facility's RN stated that care plans were updated every three months or as needed, but the smoking section was overlooked. The facility used the RAI manual as their policy for MDS and care plan updating, which was available to staff digitally.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, who had a history of Type 2 diabetes mellitus, hypothyroidism, hypertension, chronic kidney disease, and Guillain-Barre syndrome, was frequently incontinent of bladder and bowel and required extensive assistance with activities of daily living. During an observation, it was noted that CNA A did not clean between the labia or the urinary meatus while providing incontinent care. Additionally, after the resident urinated while being turned on her side, CNA A and CNA B did not clean the genital area again before placing a clean brief on the resident. Interviews with CNA A and CNA B revealed that they did not clean the resident thoroughly due to concerns about being too invasive and acknowledged the oversight of not cleaning the urinary opening. The Director of Nursing confirmed that the urinary meatus area should have been cleaned and that the resident should have been cleaned again after urination. The facility's policy on perineal care, which includes cleaning from front to back, was not followed, contributing to the risk of infection and skin breakdown for the resident.
Medication Labeling Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding the labeling of an ophthalmological solution for a resident. During an observation, it was noted that a bottle of Ciprofloxacin 0.3% ophthalmological solution, prescribed for a resident with chronic allergic conjunctivitis, was not labeled with an open date. This oversight was confirmed by a Medication Aide, who acknowledged that the medication had been previously opened and should have been marked with an open date to track its expiration. The Director of Nursing (DON) confirmed that the facility's expectation was for all medications to be labeled with their open dates, as medications like eye drops are only effective for 30 days after opening. The facility's policy, revised in January 2023, also required medications to be labeled with expiration dates in accordance with professional standards and regulations. The lack of an open date on the medication bottle could prevent staff from determining the expiration date, potentially leading to the administration of expired medications.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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