Franklin Heights Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 223 S Resler, El Paso, Texas 79912
- CMS Provider Number
- 675479
- Inspections on file
- 42
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Franklin Heights Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls, who required substantial assistance with ADLs and transfers, was observed lying in bed with the call light on the floor and out of reach, despite a care plan directing staff to keep it accessible. Staff, including CNAs, LVNs, the DON, and the Administrator, acknowledged that call lights must always be within residents’ reach and that all direct care staff are responsible for checking this, while the DON confirmed the facility had no written call light policy.
A resident with severe cognitive impairment and chronic lung disease was observed asleep in bed using oxygen via nasal cannula with an oxygen concentrator running, but no oxygen sign was posted outside the room. The resident’s care plan included PRN O2 at 2 L/min with monitoring of respiratory status. Multiple CNAs, LVNs, the SW, DON, and Administrator all stated that oxygen or “No Smoking/Oxygen in Use” signs were required outside any room with an oxygen concentrator to inform staff and visitors. Facility oxygen administration policy referenced placing “No Smoking” signs when oxygen is administered or stored, while noting that in a non‑smoking facility individual room oxygen signs are not required, yet staff and leadership consistently described posting such signs as facility practice, and this was not done for this resident.
Surveyors found that staff did not consistently keep call lights within reach for several residents with CVA, dementia, Parkinson’s disease, incontinence, and significant ADL deficits, despite care plans and staff statements requiring accessible call lights and encouraging their use. In multiple rooms, residents were observed in bed while call lights were clipped to the head of the bed, partially under a pillow, or hanging on the wall plug-in plate, and at least one resident demonstrated difficulty reaching the device due to limited arm mobility. Staff, including CNAs, LVNs, and a med aide, acknowledged they were trained and responsible for ensuring call lights were within reach, but some admitted they had not checked placement during their recent interactions with the residents, and the administrator reported there was no facility policy on call lights.
Surveyors found that the facility did not consistently complete or maintain required EMR/NAR screenings and criminal background checks for multiple staff, including the DON, CNAs, LVNs, an RN, and a social worker. Personnel files lacked evidence of annual registry checks for several employees, and criminal checks were missing for at least two rehired nurses. One social worker’s EMR/NAR check was undated due to a system outage and was not rerun. These findings showed that the facility’s written policies and HR handbook requiring pre-employment, rehire, and annual background and registry screenings were not fully implemented or documented.
The facility did not maintain a qualified full-time social worker position after the prior social worker left, and later hired an unlicensed individual into the role despite a job description requiring specific social work education or certification and LTC experience. This unlicensed social worker was responsible for developing social histories, social assessments, and care plans to address residents’ medically related social and emotional needs, and the report notes that this failure could place residents at risk of not having their psychosocial or discharge planning needs met.
Surveyors found that two residents were subjected to physical restraints in the form of pillows tucked under their bed sheets, restricting their movement and not required for medical treatment. Staff interviews and record reviews confirmed that these interventions were not care planned or medically necessary, and facility policies prohibit such practices unless indicated for medical reasons.
A resident with a PEG tube for nutrition and medication due to dysphagia was given oral medications by a CMA, contrary to the care plan and physician orders. The CMA did not review the care plan or medical record before administration, resulting in a medication error. Staff interviews confirmed the care plan was not followed, and the error was reported and investigated.
A CMA administered Amiodarone and Vitamin B12 orally to a resident who was not prescribed these medications and required all medications to be given via PEG tube due to dysphagia. The error occurred because the CMA failed to verify physician orders and did not follow the resident's care plan or established medication administration protocols, as confirmed by staff interviews and record review.
A certified medication assistant administered Amiodarone and Vitamin B12 orally to a resident with a PEG tube, despite the resident not being prescribed these medications and all orders requiring medications to be given via the feeding tube. The error was discovered after the resident reported the incident, and staff interviews confirmed that proper verification procedures were not followed, resulting in the administration of unprescribed medications by the wrong route.
A resident was not allowed to share a room with their spouse or roommate of choice, and did not receive written notice before a change in room assignment was made, violating their rights.
The facility did not ensure that residents were informed about how to contact the State Long-Term Care Ombudsman or file complaints with the State Survey Agency. Residents reported not knowing how to access these resources, and required information was missing from admission packets and not discussed during resident council meetings. Staff interviews confirmed that this information was not routinely provided or documented.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
Red dried drippings were found on a Betadine bottle in a treatment cart, with the LVN, ADON, and DON all acknowledging that bottles should be clean to prevent infection control issues. The LVN was responsible for daily cart maintenance, while the ADON and DON were tasked with regular monitoring, but the observed condition did not meet facility policy for cleanliness.
A facility failed to maintain the dignity and privacy of a resident with a catheter by not covering the urinary collection bag with a privacy bag, as required by the resident's care plan. Despite the resident's cognitive intactness and expressed discomfort with the visibility of the bag, it was repeatedly found uncovered. Staff acknowledged the oversight, which violated the resident's right to a dignified existence.
A resident with severe cognitive impairment and physical limitations was unable to reach her call light due to staff oversight, violating her right to reasonable accommodation. The resident, dependent on staff for daily activities, was left without the ability to call for assistance or access water, as both the call button and water were placed out of reach. Staff acknowledged the oversight, and the DON confirmed the importance of call light accessibility.
A resident with a suprapubic catheter was found without a catheter leg strap, contrary to care plan and physician orders, posing a risk of catheter-related trauma. The resident, who requires total assistance with toileting hygiene, was observed by an LVN without any securement device in place. The DON confirmed the importance of the strap for securing the catheter, which was supposed to be checked every shift.
A resident receiving oxygen therapy was found with an empty humidifier bottle on their oxygen concentrator, contrary to the facility's policy requiring it to be filled with distilled water. The LVN responsible acknowledged the oversight, and the DON confirmed the importance of the humidifier in preventing dry nasal passages.
The facility failed to maintain proper food storage and equipment conditions, leading to potential cross-contamination risks. Observations revealed dried drippings on soy sauce and jelly containers, unsealed ground beef releasing blood in the refrigerator, and malfunctioning kitchen equipment. The facility's policies lacked specific guidelines for refrigerator sanitation.
The facility failed to administer medication as ordered, did not follow drug destruction procedures, and did not maintain cleanliness in medication carts, leading to potential risks for residents.
The facility failed to date Glucometer Normal/High Control Solutions when opened according to manufacturer specifications in Zone 4 and Zone 5. Despite staff training, the solutions were not dated, which is required to ensure they are discarded three months after opening.
The facility failed to maintain an infection prevention and control program, leading to deficiencies such as an uncovered foley bag for a resident, torn and stained linen covers, and dirty crash carts. Staff confirmed that these practices violated infection control protocols and posed risks of contamination and infection.
The facility failed to maintain essential kitchen equipment, including an oven with a door held closed by a bungie cord and missing stove knobs. Additionally, the facility did not maintain logs for checking chemical levels in the Three-Compartment Sink, and dietary staff were not adequately trained in its use. The Maintenance Supervisor reported ongoing issues with the oven and stove, and the Administrator was unaware of some equipment problems.
The facility failed to maintain resident dignity and privacy, as staff were observed standing while feeding residents, not offering clothing protectors, and failing to cover a resident's Foley catheter bag. A resident was also left with facial hair, which she found embarrassing. These actions were against facility policies and impacted the residents' dignity.
The facility failed to post required oxygen signs outside the rooms of two residents on oxygen therapy, posing a potential fire hazard. Both residents, one with severe cognitive impairment and another with acute respiratory failure, were observed using oxygen without the specified amount in their care plans. Staff interviews confirmed the oversight, which violated the facility's policy on oxygen administration.
The facility failed to post nurse staffing data for thirty-two of fifty-two days reviewed, affecting both the East and West Wings. Missing information included the number of RNs and LVNs scheduled and their hours worked. The DON acknowledged that nurses were responsible for these postings, which are mandatory according to facility policy.
The facility failed to maintain an effective pest control program, resulting in the presence of live cockroaches in one of six zones. Cockroaches were observed in a resident's room and the hallway, and a CNA reported frequent sightings. The facility had a pest control contract and regular services, but the policy focused on the food service department.
The facility failed to follow its abuse prevention policies when an LVN reported another LVN for allegedly stealing medications from residents. The DON did not report the allegation to the Administrator or state agency, as required by policy, and only began an investigation without notifying necessary parties.
The facility failed to report an alleged medication theft in a timely manner. The DON received a report from an LVN about another nurse allegedly stealing medications but did not report it to the administrator or state agency, contrary to facility policy. The administrator and regional compliance nurse were unaware of the situation, indicating a breakdown in communication and adherence to reporting protocols.
The facility failed to investigate and report an allegation of medication theft by an LVN in a timely manner. The DON received a report of the alleged theft but did not immediately report it to the state agency, dismissing it as potentially malicious. The Administrator and Regional Compliance Nurse later acknowledged the oversight. This failure to follow reporting protocols could risk resident safety and quality of life.
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in identifying necessary therapies. A resident with severe cognitive impairment was not accurately assessed for oxygen therapy needs, despite having an order for continuous oxygen therapy. Another resident with acute respiratory failure was not accurately assessed for oxygen therapy, although her care plan indicated its necessity. A third resident with moderately impaired cognition was not accurately assessed for intravenous medication needs, despite having an order for IV antibiotics. The MDS Coordinator acknowledged the discrepancies.
The facility failed to implement comprehensive care plans for three residents, leading to unmet needs. A resident with severe cognitive impairment and a history of falls lacked a care plan reflecting fall prevention interventions. Another resident with chronic pain had no care plan for pain management, despite expressing concerns about ineffective pain relief. A third resident with a urinary catheter lacked a care plan for using a leg anchor, risking catheter-related trauma. The DON acknowledged the importance of individualized care plans to ensure residents' needs are met.
The facility failed to provide necessary grooming and hygiene services for two residents, leading to deficiencies in their care. A resident with dementia was observed with long facial hair, indicating a lack of personal hygiene assistance, while another resident with a neurocognitive disorder had long fingernails despite requests for nail care. Staff interviews revealed short staffing and a lack of specific policies contributed to these deficiencies, placing residents at risk of poor hygiene and a decline in self-esteem.
A resident with diabetes and chronic wounds had an unstageable pressure ulcer on the right heel improperly dressed, exposing the wound. LVN E observed the issue but did not notify the Wound Care Nurse, contrary to facility policy. This oversight posed an infection risk, as confirmed by the Wound Care Nurse and DON.
A facility failed to maintain continence and provide proper catheter care for a resident with dementia, hypertension, and dyslipidemia. The resident was observed with catheter tubing hanging low and sediment present, lacking a leg anchor despite facility policy. Staff confirmed the absence of the leg anchor and attributed sediment to low fluid intake, highlighting a deficiency in care.
A resident with a history of diabetes and knee replacement was at risk of infection due to the facility's failure to change a midline catheter dressing as per physician orders. The dressing was observed to be loose and had dried blood, indicating it had not been changed on schedule. Interviews with staff confirmed the oversight, highlighting a lapse in following the prescribed care plan.
A resident with chronic pain did not receive timely pain management due to a lack of follow-up on a physician's order for Tylenol 4, which was on back order. Despite the resident's requests and the physician's order, the facility failed to ensure the medication was obtained or explore alternatives, resulting in unmanaged pain.
The facility failed to report an allegation of medication theft by an LVN, as the DON did not notify the Administrator or state agency, contrary to the facility's abuse policy. This oversight left the facility at risk of not addressing potential abuse or misappropriation of resident property.
A resident with cerebral palsy and muscle contracture was left without access to her call light on two occasions. Observations and interviews revealed that the call light was placed in locations inaccessible to the resident, despite her care plan requiring it to be within reach. The facility's policy on resident rights was not followed.
A facility failed to communicate an acute increase in blood glucose levels for a resident receiving hospice services. The resident's glucose level was recorded at 349, but this was not reported to the hospice nurse, leading to potential substandard care. Interviews revealed conflicting expectations about reporting glucose levels, highlighting a communication breakdown.
The facility failed to report allegations of misappropriation and neglect involving two residents to the state agency within the required time frames, leading to a deficiency in ensuring resident safety and well-being.
A resident with Diabetes Mellitus did not receive prescribed wound care for his left and right heels on a specified date, as confirmed by multiple staff interviews and record reviews. The missed wound care left the resident at risk of wound deterioration and infection, despite the facility's policies emphasizing the importance of following physician orders.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring the call light was within reach. Record review showed the resident was an elderly male with dementia, hypertension, COPD, coronary artery disease, chronic kidney disease, and a history of falls. His annual MDS documented a BIMS score of 0, indicating severe cognitive impairment, and that he required substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and transfers. The resident’s care plan directed staff to ensure the call light was within reach and to instruct him to use it for assistance as needed. During an observation in the resident’s room, the resident was found lying in bed with the call light on the floor toward his feet, out of his reach. The resident was confused, speaking incomprehensibly, and only the word "cold" in Spanish was discernible. Multiple staff members, including CNAs and LVNs, stated in interviews that call lights were required to be within residents’ reach so they could request help, and that all direct care staff were responsible for checking this. The DON and Administrator both confirmed that call lights had to be within reach and that all nursing staff were responsible for ensuring this, and the DON further confirmed via email that the facility did not have a written policy on call lights.
Failure to Post Oxygen Sign for Resident Receiving Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to post an oxygen sign outside the room of a resident receiving oxygen therapy, contrary to facility policy and staff expectations. Record review showed the resident was an elderly female with Alzheimer’s disease, dementia, COPD, asthma/chronic lung disease, and allergic rhinitis, with an admission date of 07/21/2018. Her annual MDS dated 01/05/2026 documented a BIMS score of 0, indicating severe cognitive impairment, and active diagnoses including asthma and COPD/chronic lung disease. The resident’s care plan dated 01/13/2026 included interventions for oxygen therapy, specifying oxygen administration at 2 L/min via nasal cannula as needed for oxygen saturation at or below 90%, along with monitoring of respiratory status and interventions to support adequate oxygenation. On 03/27/2026 at 11:29 a.m., observation in the resident’s room found her asleep in bed, wearing a nasal cannula, with the oxygen concentrator turned on. Despite active oxygen use, there was no oxygen sign posted outside the resident’s room. Multiple staff interviews confirmed that the facility’s practice and expectations were that oxygen or “No Smoking/Oxygen in Use” signs be posted outside any room where oxygen therapy or an oxygen concentrator was present. CNA A, CNA B, LVN C, LVN D, the social worker, the DON, and the Administrator each stated that oxygen signs were required outside rooms with oxygen concentrators to alert staff and visitors, and they described potential negative outcomes such as staff not monitoring oxygen levels or fire hazards. Review of the facility’s undated Oxygen Administration policy stated that “No Smoking” signs should be placed in the area when oxygen is administered and stored, and that if the facility is non‑smoking, oxygen in use signs are not required on individual resident rooms. Despite this, facility leadership and staff consistently indicated that oxygen signs should be posted outside rooms with oxygen concentrators, and on the date of observation, no such sign was posted for this resident while oxygen was in use.
Failure to Maintain Accessible Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that multiple residents had call lights within reach, despite care plans and staff statements indicating that call lights should always be accessible and used for assistance. For one male resident with a history of diabetes, multiple CVAs with left-sided paralysis, left below-knee amputation, mental illness, and significant ADL dependence, the care plan and bedside report instructed staff to encourage use of the call bell for assistance. Staff, including the social worker, LVNs, and CNAs, consistently reported that this resident was able to use the call light and that all staff were trained and responsible for keeping call lights within reach. However, during observation, the resident was in bed with the call light clipped to the head of the bed on his right side; he demonstrated difficulty reaching it due to limited right arm movement and inability to see where it was clipped, and he stated it was hard to reach at times. Another female resident with Parkinson’s disease, dementia, impaired vision, bowel and bladder incontinence, and an ADL deficit had a care plan directing staff to anticipate and meet needs, ensure the call light was within reach, encourage its use, and respond promptly to requests. During observation while she was eating breakfast in bed, the call light was clipped to the pillowcase, slightly under the pillow, and not within her reach. The resident stated she used the call light for assistance and confirmed she could not reach it in its observed position, explaining that staff usually clipped it next to the side of the bed close to her arm. A medication aide who had administered medications earlier that morning acknowledged she had not noticed the call light was out of reach and then repositioned it. An LVN later stated she checked call lights during rounds but did not know who had served the breakfast tray. A male resident with vascular dementia, depression, diabetes, frequent falls, impaired cognition, and incontinence had a care plan requiring that his call light be within reach and that he be encouraged to use it. During observation, he was lying in bed watching TV with the call light hanging on the wall plug-in plate by the head of the bed, not within his immediate reach, and he did not respond to the surveyor’s questions. A CNA stated this resident was oriented, ambulatory with a walker, able to use his call light, and that he did not like to use it and preferred to hang it on the wall, while also stating staff were trained to keep call lights within reach. The administrator also observed the call light hanging on the wall plate and reiterated that staff were trained to keep call lights within reach. Another male resident with hypertensive heart disease, OCD, vascular dementia, multiple cerebral infarcts, orthostatic hypotension, repeated falls, and bowel and bladder incontinence had a care plan instructing staff to ensure the call light was within reach and to encourage its use. During observation, he was lying in bed awake with the call light hung on the wall plug-in plate by the head of the bed. He was alert and oriented to person and place and able to answer simple questions but did not answer when asked if he could use his call light. The administrator confirmed the call light’s placement on the wall plate. A CNA later stated this resident used his call light at times and that she normally checked call light placement at the start of her shift but had been late that day and had not checked. An LVN also stated the resident used his call light at times for assistance. A further male resident with vascular dementia, diabetes, CVA with right hemiplegia, contracture of the right hand, impaired vision, and an ADL self-care deficit had a care plan noting his preference for the call light to be placed in bedside drawers and directing staff to ensure the call light was within reach and encourage its use. During observation, he was lying in bed watching TV, oriented to person and place, and the call light was hung on the wall plug-in plate by the head of the bed. He stated he was able to walk and did not use the call light for assistance. When an LVN entered with the surveyor, he observed the call light on the wall plate and then placed it within reach, while stating that staff were trained to keep call lights within reach and that he checked placement at the start of the shift and during rounds. The administrator later stated she had been informed by corporate staff that the facility did not have a policy on call lights.
Failure to Maintain Required Background and Registry Checks for Staff
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain required screening policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Surveyors found that the facility did not have complete or current Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) checks, and did not complete required criminal background checks for multiple staff members. These failures occurred despite written facility policies requiring criminal history checks and registry screenings prior to hire, upon rehire, and annually thereafter, in accordance with Texas Health and Safety Code, Chapter 250, and the facility’s HR Personnel Handbook. During interviews and record reviews with the HR Coordinator and administrator, surveyors identified missing or incomplete documentation for 7 of 10 employees reviewed for EMR/NAR screenings and 2 of 10 employees reviewed for criminal checks. For RN O, rehired on 02/23/24, the HR Coordinator could not locate a criminal background check in the personnel file and found only one EMR/NAR check dated 01/20/25, with no evidence of annual follow-up. For CNA P, CNA L, LVN D, LVN N, and the DON, the most recent EMR/NAR checks on file were dated in January or February 2025 and were completed by the previous HR Coordinator, with no prior annual checks available in their personnel files to demonstrate ongoing compliance with the facility’s policy. Additional deficiencies were identified for specific staff. For Social Worker B, whose date of hire was 09/18/25, the initial EMR/NAR report in the file was not dated; the HR Coordinator stated that the Tulip system was down when the check was completed and that she did not rerun the check once the system was operational. For LVN N, rehired on 12/01/23, and RN O, the HR Coordinator reported she could not find any criminal background check reports to show that criminal checks were completed upon rehire. The facility’s written policies and HR handbook require comprehensive background checks, including OIG, EMR/NAR, criminal history, and other databases, prior to employment and annually thereafter, but the documentation reviewed did not demonstrate that these requirements were consistently carried out or maintained in personnel files.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker despite being licensed for 132 beds, resulting in a deficiency related to social services staffing. Record review and interview with the administrator and HR Coordinator showed that the previous social worker’s last day was 08/05/25, and from that date the facility did not have a qualified full-time social worker in place. On 09/18/25, the facility hired Social Worker B, who, according to the administrator, did not have a social work license at the time of hire and was only scheduled to take the licensing test at a later date. The job description signed by Social Worker B required at least a bachelor’s degree in social work or secondary education in social services with certification as a social worker designee, along with LTC experience and responsibilities such as developing social histories, social assessments, and care plans addressing residents’ medically related social and emotional problems and needs. The report states that this failure could place residents at risk of not having their psychosocial or discharge planning needs met. The deficiency is based on the facility’s failure, since 08/05/25, to ensure that the social worker position was filled by an individual meeting the stated qualification criteria on a full-time basis, as required for a facility of its size.
Failure to Prevent Use of Physical Restraints Not Medically Indicated
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from physical restraints not required to treat medical symptoms, specifically for two residents. Both residents were found with pillows tucked under their bed sheets, which restricted their movement and ability to get out of bed. These interventions were not documented in their care plans as medically necessary, nor were they listed as required devices for fall prevention or other medical needs. Staff interviews confirmed that the use of pillows in this manner was not part of the residents' care plans and was not medically indicated. One resident, a female with severe cognitive impairment, multiple neurological and psychiatric diagnoses, and a history of falls, was observed lying in bed with a long body pillow tucked under her bed sheet. Staff, including CNAs and nurses, acknowledged that the pillow was used to prevent the resident from falling out of bed due to her constant movement, but also confirmed that this practice was not permitted and was considered a restraint. The resident's care plan included fall precautions such as low beds and floor mats, but did not mention the use of pillows as a restraint or intervention. A second resident, a male with severe cognitive impairment, muscle weakness, and a history of stroke, was also found with a pillow propped under his bed sheet. This resident was dependent on staff for all activities of daily living and was unaware of the presence of the pillow. Staff interviews and review of facility policies confirmed that the use of such devices was not allowed unless medically necessary and care planned. Facility policies and staff training materials reviewed by surveyors emphasized the prohibition of restraints for discipline or convenience, and staff were trained not to use pillows or similar devices in this manner.
Failure to Implement Person-Centered Care Plan for Medication Administration
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames to meet a resident's medical and nursing needs. The resident, an older adult male with a history of left middle cerebral artery stroke, urinary tract infection, and metabolic encephalopathy, was dependent on a PEG tube for nutrition, hydration, and medication administration due to dysphagia and unsafe oral intake. The care plan clearly indicated that all medications were to be administered via the PEG tube, and that the resident was not safe for oral intake of food or medications. Despite these documented requirements, a certified medication assistant (CMA) administered oral medications to the resident, placing pills in his mouth for him to swallow. The resident reported this incident, stating that he was supposed to receive medications through his PEG tube per physician orders. Interviews with staff confirmed that the CMA did not review the care plan or medical record before administering the medications, resulting in the resident receiving medications by an incorrect route. The nurse practitioner and other staff confirmed that the medication given was not prescribed to the resident and that the error occurred due to failure to follow the care plan and medication orders. The facility's policy required all medication staff to verify the physician's orders and the resident's care plan before administering any medications. Multiple staff interviews confirmed that the care plan was not followed, and the CMA responsible initially denied the error before admitting to it during the investigation. The incident was reported by other staff members, and the resident was monitored for complications following the medication error. The deficiency was attributed to the failure of staff to review and implement the resident's care plan as required.
Medication Error: Unprescribed Oral Administration of Amiodarone and Vitamin B12
Penalty
Summary
A deficiency occurred when a certified medication assistant (CMA) administered Amiodarone, a heart medication, and Vitamin B12 to a resident who was not prescribed these medications. The resident, who had a history of stroke, dysphagia, and required a PEG tube for all nutrition and medication administration, was given the medications orally, contrary to physician orders and the resident's care plan. The resident reported that the nurse insisted he take the pills by mouth, despite his objections and the established protocol for PEG tube administration. Record reviews confirmed that the resident did not have active orders for Amiodarone or Vitamin B12, and that all medications were to be administered via the PEG tube due to unsafe swallowing. Interviews with staff, including the nurse practitioner, LVNs, and the DON, corroborated that the CMA failed to verify the medication orders and did not follow the required procedures for medication administration. The facility's policy and staff training emphasized the necessity of verifying physician orders, following the seven rights of medication administration, and ensuring medications are given by the correct route. The incident was identified after the resident reported receiving the wrong medications, prompting staff to review the medication administration records and care plan. The CMA involved was placed on investigatory suspension, and staff interviews confirmed that the error resulted from not checking the MAR and care plan prior to administration. The facility's documentation and staff statements indicated that the error was preventable and occurred due to failure to adhere to established medication administration protocols.
Significant Medication Error: Unprescribed Oral Medication Administered via Wrong Route
Penalty
Summary
A significant medication error occurred when a certified medication assistant (CMA) administered Amiodarone and Vitamin B12 to a male resident who was not prescribed these medications. The resident had a history of a left middle cerebral artery stroke, dysphagia requiring a PEG tube for all nutrition and medication administration, and moderately impaired cognition. According to the care plan and physician's orders, the resident was not safe for oral intake and all medications were to be given via the PEG tube. Despite these orders, the CMA gave the resident oral pills, which the resident swallowed after being told by the staff that he needed to take them, even though he expressed reluctance. The error was discovered after the resident reported the incident to another nurse, who then escalated the issue to the Director of Nursing (DON) and the nurse practitioner (NP). Interviews with staff confirmed that the medications given were not prescribed for the resident, and that Amiodarone, in particular, is a high-risk cardiac medication that should only be administered when specifically ordered. The facility's medication administration policy requires staff to verify physician orders, the medication administration record (MAR), and the resident's identity before administering any medication. In this case, the CMA failed to follow these protocols, resulting in the administration of unprescribed medications by the wrong route. Staff interviews further revealed that all licensed and certified staff are responsible for verifying medication orders and following the seven rights of medication administration. The DON and other staff confirmed that the CMA did not check the MAR or the care plan before giving the medications, and that the resident was not prescribed Amiodarone or Vitamin B12 at the time. The incident was attributed to the CMA confusing residents during medication pass and not adhering to established procedures for medication verification and administration.
Failure to Honor Resident's Roommate Choice and Provide Written Notice
Penalty
Summary
A deficiency was identified when the facility failed to honor a resident's right to share a room with their spouse or roommate of choice. Additionally, the resident did not receive written notice prior to a change being made to their room assignment. This action was not in accordance with the resident's rights as outlined in regulatory requirements.
Failure to Provide Residents with Advocacy and Complaint Information
Penalty
Summary
The facility failed to ensure that residents received information and contact details for State and local advocacy organizations, including the State Survey Agency and the State Long-Term Care Ombudsman program, in a language and format they understood. Record review of monthly resident council minutes for the past six months showed no documentation of discussions regarding how to file a complaint with the state agency or review of ombudsman information. During a confidential group meeting, all seven residents present stated they did not know how to contact the ombudsman or file a complaint with the state agency, although they recalled being given a brief overview of the program and the ombudsman's name. The facility's admission packet was found to lack the required grievance procedure section and did not include state agency or ombudsman contact numbers. Interviews with the Administrator and Activities Director revealed that while residents were told they could file grievances with facility staff, information about filing complaints directly with the state or contacting the ombudsman was not routinely provided or documented. The Administrator stated that state and ombudsman information was only given if specifically requested by residents or families, and the Activities Director confirmed that the process for contacting the state agency was not explained or documented during resident council meetings. Although ombudsman information was posted at the facility entrance, residents were not consistently informed about their rights or the procedures for filing complaints with external agencies.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pests within the facility environment. No additional details regarding specific residents, staff, or observed pest activity were provided in the report.
Unclean Betadine Bottle Found in Treatment Cart
Penalty
Summary
A deficiency was identified when red dried drippings were observed on a Betadine bottle stored in the treatment cart. The Treatment LVN acknowledged that all bottles should be clean and free of dried drippings, recognizing that such residue poses an infection control issue that could affect residents. The LVN stated he was responsible for maintaining the treatment cart, including ensuring the cleanliness of all bottles. Further interviews with the ADON and DON confirmed that the Treatment LVN was expected to review and maintain the cleanliness of the treatment cart daily, specifically ensuring bottles were free from dried drippings. The ADON and DON also stated they were responsible for monitoring all carts for cleanliness on a regular basis. The DON, who also serves as the Infection Preventionist, emphasized that dried drippings on the Betadine bottle could lead to bacteria accumulation and contamination. A review of the facility's policy indicated that medication carts should be maintained and cleaned, but the observed condition of the Betadine bottle did not meet these standards.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident by not covering the urinary collection bag with a privacy bag. This deficiency was observed in the case of a male resident with neuromuscular dysfunction of the bladder, who had an indwelling catheter. Despite the resident's cognitive intactness, as indicated by a BIMS score of 15, and his care plan specifying that the catheter bag should be in a privacy bag, the collection bag was repeatedly found uncovered and visible from the hallway. Observations and interviews revealed that the catheter collection bag was not placed in a privacy bag on multiple occasions, even though the resident expressed discomfort with the visibility of the bag. Staff, including an LVN and the DON, acknowledged the oversight and confirmed that it was the responsibility of nurses and CNAs to ensure the bag was covered. The facility's policies on catheter care and resident rights emphasized the importance of privacy, yet these were not adhered to, resulting in a violation of the resident's right to a dignified existence.
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 violation of the resident's right to reasonable accommodation of needs and preferences. The resident, a female with multiple diagnoses including cerebral palsy, vascular dementia, and paraplegia, was observed lying in bed with her call button clipped onto the cord near the call light outlet, out of her reach. The resident expressed that she could not reach the call button due to her contracted hand and needed staff assistance to access water, which was also placed out of her reach. The resident was dependent on staff for various daily activities and had severe cognitive impairment, as indicated by a BIMS score of 01. During interviews, staff members acknowledged that the call button was left out of the resident's reach after she was returned to her room following a shower. The Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) involved admitted that they must have forgotten to clip the call pad within the resident's reach. The Director of Nursing (DON) confirmed the importance of having the call light within reach for residents to call for assistance and acknowledged the risk posed by the call button being out of reach. The facility's Resident Rights policy emphasizes the right to reasonable accommodation of resident needs, which was not adhered to in this instance.
Failure to Secure Catheter Poses Risk to Resident
Penalty
Summary
The facility failed to ensure that a resident with a suprapubic catheter received appropriate care to prevent urinary tract infections and potential catheter-related trauma. The resident, a cognitively intact male with neuromuscular dysfunction of the bladder and a history of urinary tract infections, was observed without a catheter leg strap in place. This strap is essential for securing the catheter and preventing it from being pulled, which could cause pain and discomfort. The resident required total assistance with toileting hygiene and substantial assistance with other activities of daily living. During an observation, a Licensed Vocational Nurse (LVN) noted the absence of any securement device for the catheter, such as tape or a strap, which contradicted the resident's care plan and physician's orders. The Director of Nursing (DON) confirmed that the purpose of the catheter strap was to hold the tubing in place and that its placement was supposed to be monitored by nursing staff every shift. Despite the resident not having experienced a catheter pull-out incident at the facility, the lack of a securement device posed a risk of pain and trauma.
Failure to Maintain Oxygen Humidifier for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not ensuring that the oxygen humidifier bottle on the oxygen concentrator was filled with water. This deficiency was observed in Resident #12, who was receiving oxygen therapy due to conditions such as pulmonary hypertension, chronic obstructive pulmonary disease, pulmonary fibrosis, and chronic respiratory failure with hypoxia. During an observation, it was noted that the humidifier bottle was empty, and the resident was unaware of how long it had been in this state. The resident was not in distress at the time of the observation. Interviews with the staff, including an LVN and the DON, revealed that the humidifier bottle should have contained water to humidify the oxygen being administered to the resident. The LVN acknowledged the oversight and stated it was her responsibility to check the oxygen concentrator during her shift. The DON confirmed the purpose of the humidifier and noted that the nurse assigned to the hall was responsible for checking the humidifier bottle. The facility's Oxygen Administration policy requires the humidifier container to be filled with distilled water, which was not adhered to in this instance.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen's sanitation and food storage practices. Specifically, a gallon bottle of soy sauce and a plastic container of jelly in the walk-in refrigerator were found with dried drippings and food residue on their lids, respectively. Additionally, food items in the refrigerator were not stored in sealed containers, with ground beef thawing on a metal tray releasing blood drippings onto the floor. These conditions were acknowledged by the Dietary Manager, who noted the risk of cross-contamination and potential foodborne illness to residents. Further observations revealed that the kitchen's equipment was not in proper working condition, with an oven door secured by a bungee cord and missing burner knobs on a stove. The facility's infection control policy, dated 2012, lacked specific guidelines for the safe storage of food in the refrigerator and did not address the hygiene and sanitation of the refrigerator. The in-service training attendance roster from February 2024 outlined cleaning schedules but did not include specific instructions for refrigerator sanitation.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to administer medication to a resident according to the physician's order. Specifically, a medication aide held the administration of Losartan 100 mg, which was prescribed to be given once daily in the morning for hypertension, without any parameters to hold the medication. The medication aide did not consult with the licensed vocational nurse (LVN) regarding the necessity to hold the medication, leading to the medication not being administered as ordered. This was confirmed by the physician and the Director of Nursing (DON), who stated that the medication should have been administered as there were no parameters to hold it. Additionally, the facility did not follow its policy and procedure on drug destruction. The administrator did not have copies of the Individual Control Drug Records for 21 out of 31 controlled substances pending drug destruction. These records are necessary to reconcile the controlled substances with the pharmacist during drug destruction to prevent drug diversion. The discrepancy was discovered during an observation and interview with the DON and Corporate Nurse Consultant, who confirmed that the administrator was missing these records. Furthermore, the facility failed to maintain cleanliness in the medication carts. An observation revealed that one of the medication carts used in Zone 4 and Zone 5 had dried stains and small particles in one of the drawers where medication blister packets are stored. The LVN acknowledged that the medication carts should be cleaned at least once a week, indicating a lapse in maintaining the cleanliness and hygiene of the medication storage areas.
Failure to Date Glucometer Control Solutions
Penalty
Summary
The facility failed to ensure that Glucometer Normal/High Control Solutions were dated when opened according to manufacturer specifications in Zone 4 and Zone 5. During an observation and interview, it was revealed that the Glucose Control Solutions had not been dated when opened, despite the manufacturer's instructions to discard the solutions three months after opening. The LVN confirmed that licensed staff had been trained to write the date on the box and/or the control solution bottles when opened. The DON also confirmed that staff had been trained to date the bottles and discard them according to the manufacturer's specifications. A review of the facility's Glucometer policy and the Blood Glucose Monitoring System User's Guide corroborated the requirement to date the bottles and discard them after three months.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies. Resident #58's foley bag was observed hanging from a trash can near the floor and not covered by a privacy bag, which violates infection control protocols and resident privacy. Interviews with the resident and staff confirmed that the bag should have been covered and properly positioned to prevent infection and maintain dignity. The Director of Nursing (DON) acknowledged that the situation was unacceptable and posed a risk of infection and embarrassment for the resident. In the laundry room, a linen container was found covered with a black plastic cover that had multiple tears. Additionally, a PVC plastic frame 4-shelf linen cart was observed with multiple white stains, broken shelves held together with a metal clothes hanger and yellow duct tape, and disposable briefs and metal teaspoons stored on the third shelf. The Housekeeping/Laundry Supervisor confirmed that the linen covers should be clean and free of stains, and supplies should not be stored in clean linen carts to prevent cross-contamination. Two crash carts were found with dust, small paper particles, and dried stains on the shelves where suction machines were stored. The DON stated that licensed staff on the night shift were responsible for cleaning the crash carts during their checks. Additionally, a linen cart was observed uncovered and unattended in a resident-use area, with an unidentified resident moving towels around in it. The cart contained various clean linens and open medication cups with white cream. Staff interviews confirmed that linen carts should be covered when unattended to prevent contamination.
Failure to Maintain Essential Kitchen Equipment and Proper Sanitation Procedures
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, including an oven with a door held closed by a bungie cord and missing stove knobs. The Dietary Manager revealed that the oven had not been working for over a month, and the stove knobs had been missing for about three months. Additionally, the foot pedal of the trash can next to the handwashing sink in the kitchen was not working, and the facility did not maintain logs to show that they were checking the chemical levels in the Three-Compartment Sink, as required by the posted procedures. Dietary staff were unaware of the correct procedures for using the Three-Compartment Sink and had not been adequately trained in its use. The Maintenance Supervisor reported that the issues with the oven and stove had been ongoing for 2-3 months due to difficulties in obtaining parts from the vendor. The parts were ordered, but delivery was still pending. The Administrator was aware of the oven door issue but was not informed about the missing stove knobs or other equipment problems. The Dietitian, who started working at the facility in March, stated that it was not part of her regular duties to inspect the kitchen during her monthly visits and was unaware of any equipment problems. The facility also failed to maintain one of six clean linen carts in safe operating condition. The Corporate Traveling Certified Dietary Manager and Dietary Staff #1 confirmed that the facility did not have logs to show that they were checking the chemical levels in the Three-Compartment Sink. The Dietary Manager, who had started working at the facility four days prior, acknowledged the need to address the identified concerns in the kitchen. The Administrator reported that the area director had contacted a vendor to obtain replacement parts for the oven door, but delivery was still pending.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several observations and interviews. Staff members were observed standing while feeding residents in the main dining room, which is against the facility's policy and considered a dignity issue. This was noted with Resident #16, where both a CNA and the DON were seen standing while assisting with feeding, despite being instructed to sit to ensure proper eye contact and monitoring of the resident's swallowing. Interviews with staff confirmed that sitting while feeding is necessary to prevent negative outcomes such as choking or aspiration. Resident #54 was not offered a clothing protector during meals, resulting in his clothing being soiled with food. Despite his cognitive impairments and tendency to eat with his hands, staff failed to consistently offer or ensure the use of a clothing protector. Interviews with various staff members revealed a lack of consistent practice in offering clothing protectors, with some staff citing being too busy or the resident's refusal as reasons for not providing one. The DON acknowledged that not using a clothing protector could impact the resident's dignity and should be documented in the care plan if refused. Resident #58's privacy was compromised as his Foley catheter bag was not covered with a privacy bag while he was in bed, contrary to his care plan instructions. Observations showed the catheter bag hanging from a trash can and later from a bed rail without a dignity bag, posing a risk of infection and embarrassment for the resident. Interviews with nursing staff confirmed the expectation for catheter bags to be covered at all times to maintain privacy. Additionally, Resident #89 was observed with long facial hair, which she found embarrassing. Despite her care plan indicating the need for assistance with personal hygiene, including shaving, staff interviews revealed inconsistencies in offering or performing this care, with no specific policy in place for shaving female residents.
Failure to Post Oxygen Signs for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required oxygen therapy, as observed during a survey. Both residents were on oxygen therapy, but there were no oxygen signs posted outside their rooms, which is a requirement according to the facility's policy. Resident #88, a male with a history of tongue and thyroid cancer, alcohol cirrhosis, and severely impaired cognition, was observed using oxygen via nasal cannula, but his care plan did not specify the oxygen amount. Similarly, Resident #196, a female diagnosed with acute respiratory failure with hypoxia, was also on oxygen therapy, but her care plan left the oxygen amount blank. Both residents confirmed their need for oxygen during interviews. Interviews with facility staff, including an LVN and the DON, revealed that it was the nurses' responsibility to place oxygen signs outside rooms where oxygen was in use. The absence of these signs was acknowledged as a potential fire hazard, as they serve to alert everyone to the presence of oxygen and the associated precautions, such as no smoking. The facility's Oxygen Administration policy mandates the placement of 'NO SMOKING' signs in areas where oxygen is administered and stored, highlighting the deficiency in adhering to this policy.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted and readily accessible to residents and visitors for thirty-two of fifty-two days reviewed. This deficiency was observed across both the East and West Wings of the facility on multiple dates spanning from October 2023 to December 2023. The missing information included the number of RNs and LVNs scheduled to work and the hours they worked. This lack of posting could potentially prevent residents, their families, and visitors from accessing important staffing information. During an interview, the Director of Nursing (DON) acknowledged that the nurses were responsible for filling out the staffing postings. The DON admitted that not filling out the staffing postings could result in families, residents, and visitors being unaware of the staffing levels available to provide services to the residents. The facility's document titled 'Mandatory Postings' dated May 16, 2019, indicated that the daily staffing by shift of licensed and unlicensed nursing staff was mandatory, yet this requirement was not consistently met.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live cockroaches in one of six zones (Zone 1 Rooms 1-12). During an observation on 05/29/2024 at 11:09 AM, two large cockroaches were found crawling on the floor in room [ROOM NUMBER]. One of the cockroaches was stepped on by Surveyor R as it ran into the hallway. The Administrator confirmed the presence of the roaches and acknowledged that they posed a contamination risk. A CNA reported seeing roaches every other day or two, particularly in the main shower and bathroom areas. The facility had a pest control contract and regular monthly services, but the policy dated 2012 focused on maintaining an insect and vermin-free food service department, indicating a possible gap in broader pest control measures.
Failure to Report and Investigate Alleged Medication Theft
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, specifically regarding the misappropriation of property. An allegation was made by an LVN that another LVN was stealing medications from residents. The Director of Nursing (DON) received this report but did not follow the facility's abuse policy, which required immediate reporting, investigation, and protection of residents from further potential abuse. The DON admitted to not reporting the allegation to the Administrator or the state agency, as mandated by the facility's policy and state law. The facility's abuse and neglect policy clearly states that any person with reasonable cause to believe that an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report it to the DON, Administrator, and state or adult protective services. Despite this, the DON only began an investigation without notifying the necessary parties. The Administrator and Regional Compliance Nurse were unaware of the situation until later, and the failure to report the incident to the state agency was a direct violation of the facility's policy and state and federal requirements.
Failure to Report Alleged Medication Theft
Penalty
Summary
The facility failed to report an alleged violation involving misappropriation of medications in a timely manner, as required by state and federal regulations. The Director of Nursing (DON) received a report from an LVN about another nurse allegedly stealing medications from residents. Despite the facility's policy requiring immediate reporting of such allegations to the administrator and state agency, the DON did not report the incident to the administrator or the state agency. This inaction was contrary to the facility's Abuse/Neglect policy and the Long Term Care Regulatory Provider Letter, which mandates reporting of suspected abuse, neglect, exploitation, or misappropriation of resident property. During interviews, the DON admitted to receiving the report but dismissed it as a malicious allegation without further investigation or reporting. The administrator and regional compliance nurse were unaware of the situation until later, indicating a breakdown in communication and adherence to reporting protocols. The facility's policy clearly states that any person with reasonable cause to believe in the occurrence of abuse, neglect, or exploitation must report it to the appropriate authorities, which was not followed in this case.
Failure to Investigate and Report Medication Theft Allegation
Penalty
Summary
The facility failed to ensure that allegations of medication theft were thoroughly investigated and reported in accordance with state law. On May 30, 2024, the Director of Nursing (DON) received a report from an LVN alleging that another LVN was stealing medications from residents. Despite the seriousness of the allegation, the DON did not immediately report the incident to the state agency as required. Instead, the DON dismissed the report as potentially malicious, based on past behavior of the reporting LVN, and only began an investigation two days after the initial report. During an interview, the Administrator and Regional Compliance Nurse were made aware of the situation and acknowledged that the incident should have been reported to the state agency upon receipt of the allegation. The facility's policies clearly state that any suspected abuse, neglect, or misappropriation of resident property must be reported promptly to the appropriate authorities. The failure to act in accordance with these policies could place residents at risk for abuse, neglect, exploitation, and misappropriation of property, thereby decreasing their quality of life.
Inaccurate Resident Assessments for Oxygen and IV Therapy
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in identifying necessary therapies. Resident #88, a male with severe cognitive impairment and diagnosed with cancer and muscle weakness, was not accurately assessed for oxygen therapy needs in his admission MDS. Despite having an order for continuous oxygen therapy and a care plan indicating shortness of breath, the MDS did not reflect this requirement. Observations confirmed the use of an oxygen concentrator in his room, and the resident acknowledged the need for oxygen to breathe. Similarly, Resident #196, a female with acute respiratory failure and intact cognition, was not accurately assessed for oxygen therapy in her admission MDS. Although her care plan and orders indicated the use of oxygen therapy for maintaining oxygen saturation levels, the MDS failed to document this need. Observations confirmed the presence of an oxygen concentrator in her room, and the resident confirmed the necessity of oxygen use. Resident #198, a male with moderately impaired cognition and diagnosed with diabetes and end-stage renal disease, was not accurately assessed for intravenous medication needs in his admission MDS. Despite having an order for intravenous antibiotics for osteomyelitis and a care plan reflecting this treatment, the MDS did not include this information. Observations confirmed the presence of an IV line, and the resident acknowledged receiving antibiotics through it. The MDS Coordinator acknowledged the discrepancies, attributing them to the nursing staff's responsibility to update the MDS with accurate information.
Deficiencies in Person-Centered Care Plans
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 #16, who had severe cognitive impairment and a history of falls, did not have a care plan that reflected the interventions staff were using to prevent falls, such as keeping him near the nurse's station for close monitoring and using a fall mat. The Director of Nursing (DON) acknowledged the importance of individualized care plans and noted that the lack of such plans could result in unmet care needs. Resident #49, who experienced chronic pain due to paraplegia and polyneuropathy, did not have a care plan addressing her pain management. Despite being prescribed multiple pain medications, she expressed concerns about the facility's responsiveness to her requests for more effective pain relief. The DON confirmed that a care plan for pain management was necessary to ensure effective control of the resident's pain and prevent missed interventions. Resident #89, with severe cognitive impairment and an indwelling urinary catheter, lacked a care plan for the use of a leg anchor to prevent catheter-related trauma. Observations revealed sediment in the catheter tubing and a strong urine odor, indicating potential issues with catheter care. The DON stated that a care plan should include the use of a leg anchor to secure the catheter and prevent harm, such as bleeding or accidental removal. The facility's policy emphasized minimizing friction or movement at the catheter insertion site, which was not reflected in the resident's care plan.
Deficiencies in Resident Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide necessary grooming and hygiene services for two residents, leading to deficiencies in their care. Resident #89, who has a diagnosis of dementia and severely impaired cognition, was observed with long facial hair, indicating a lack of personal hygiene assistance. Despite being unable to communicate effectively, Resident #89 expressed embarrassment about her facial hair. Interviews with staff revealed that due to short staffing, residents often missed scheduled showers, and there was no specific policy addressing the removal of facial hair for female residents. The care plan for Resident #89 indicated a need for assistance with personal hygiene, but this was not adequately provided. Resident #77, diagnosed with a neurocognitive disorder and hydrocephalus, was observed with long fingernails, despite his care plan requiring regular nail trimming. His spouse had requested nail care, but it was not provided until after a grievance was filed. Staff interviews indicated that short staffing contributed to the neglect of nail care, posing a risk of injury to the resident. The facility lacked a policy to ensure proper ADL care, and staff were not adequately trained to meet residents' grooming needs. The report highlights the facility's failure to maintain good grooming and hygiene for residents who are unable to perform these tasks independently. The lack of specific policies and adequate staffing contributed to the deficiencies observed in the care of Residents #89 and #77. These deficiencies placed residents at risk of poor hygiene and a decline in self-esteem, as they were not receiving the necessary assistance to maintain their personal appearance.
Failure to Properly Manage Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as per the comprehensive assessment and professional standards. The resident, a 67-year-old male with diabetes, end-stage renal disease, and chronic right foot wounds, was admitted to the facility with unstageable pressure ulcers on the right heel and calf. The physician's orders required the application of Santyl ointment and a specific dressing regimen. However, the dressing was not applied according to these orders, leaving the unstageable right heel exposed. Observations revealed that the dressing was improperly placed, exposing the wound, which posed a risk of infection. LVN E observed the issue but failed to notify the Wound Care Nurse immediately, which was against the facility's policy. The Wound Care Nurse confirmed that he was not informed about the dressing needing attention and emphasized the infection control risk of the exposed wound. The Director of Nursing also stated that the dressing should have been changed or the Wound Care Nurse notified immediately to prevent infection risks.
Deficiency in Catheter Care and Continence Maintenance
Penalty
Summary
The facility failed to provide appropriate care for a resident who was initially continent of bladder and bowel upon admission, specifically in maintaining the resident's continence and ensuring proper catheter care. The resident, who had a diagnosis of dementia, hypertension, and dyslipidemia, was observed with catheter tubing hanging low, almost touching the floor, and sediment present in the tubing. The resident's care plan indicated the need for encouragement to drink liquids due to a history of UTIs, yet the resident was not on antibiotics and lacked a leg anchor for the catheter, which was confirmed by the LVN. Further observations revealed that the resident continued to lack a leg anchor for the catheter, despite the facility's policy requiring it to prevent catheter pulling and potential harm. Interviews with staff confirmed the absence of the leg anchor and the presence of sediment in the tubing, attributed to the resident's low fluid intake. The facility's catheter care policy did not address the use of leg anchors, and the ADON confirmed that staff should ensure the presence of leg anchors to secure catheters and prevent trauma or injury to residents.
Failure to Follow Physician Orders for IV Dressing Changes
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, specifically in the care and maintenance of a midline/PICC line. A resident, who was admitted to the facility with a history of borderline diabetes, total knee replacement, and infection of a prosthesis, was observed with a midline catheter dressing that was loose and had dried blood, indicating it had not been changed as per physician orders. The resident's care plan required dressing changes every seven days, but the dressing was observed to be dated beyond the scheduled change, placing the resident at risk of infection. Interviews with the resident and staff revealed that the dressing had not been changed in accordance with the physician's orders. The resident confirmed that the dressing was changed only after a significant delay, and a Licensed Vocational Nurse (LVN) acknowledged that the dressing should have been changed earlier. The Director of Nursing (DON) also confirmed that failure to follow the physician's orders for dressing changes could lead to an increased risk of infection for the resident.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who required such services, consistent with professional standards of practice and the resident's goals and preferences. The resident, who had a history of chronic pain due to paraplegia and polyneuropathy, expressed concerns about the ineffectiveness of her current pain medication, Tylenol 3, and requested an increase to Tylenol 4. Although the physician ordered the change, the medication was not administered due to a lack of follow-up on its availability. The resident's medical records indicated that the order for Tylenol 4 was placed but not fulfilled, as the medication was on back order. Despite the resident's repeated requests and the physician's order, the facility did not ensure the medication was obtained or explore alternative solutions. Interviews with the resident and staff revealed a lack of communication and follow-up regarding the medication's availability, leading to the resident's continued experience of unmanaged pain. The Director of Nursing acknowledged that the nursing staff should have followed up on the delay in obtaining the medication, which could have led to a timely resolution or alternative pain management strategies. The facility's policy on pain management emphasized the need for effective management through prescribed medications and comfort measures, which was not adhered to in this case.
Failure to Report Alleged Medication Theft
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, as evidenced by the mishandling of an allegation of medication theft. The Director of Nursing (DON) received a report from an LVN accusing another LVN of stealing medications from residents. Despite the seriousness of the allegation, the DON did not report the incident to the Administrator or the state agency as required by the facility's abuse policy. The DON admitted to only beginning her investigation and did not follow the protocol for reporting such allegations, which includes notifying the state agency immediately. The facility's internal policies clearly state that any suspicion of abuse, neglect, exploitation, or misappropriation of resident property must be reported to the appropriate authorities, including the state agency. However, the DON failed to adhere to these policies, leaving the facility at risk of not addressing potential abuse or misappropriation of resident property. The Administrator and Regional Compliance Nurse were unaware of the situation until later, indicating a breakdown in communication and protocol adherence within the facility.
Failure to Provide Reasonable Accommodation for Resident's Call Light Access
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs for a resident with cerebral palsy, muscle weakness, and muscle contracture. On two occasions, the resident was left alone in her room without being able to reach her call light. Observations revealed that the call light was placed in locations that the resident could not access due to her physical limitations. Despite the resident's communication problem and impaired cognition, staff did not ensure that the call light was within her reach, which is a requirement stated in her care plan. During an observation, the resident was found in bed, unable to reach her call light, and requested assistance from the state surveyor. The call light was initially found under the bed sheet near her elbow and later under her pillow, both positions making it inaccessible for the resident. Interviews with the resident and staff confirmed that the resident could not use the call light unless it was placed on her chest. The facility's policy on resident rights states that residents have the right to reasonable accommodation of their needs and preferences, which was not adhered to in this case.
Failure to Communicate Acute Glucose Level Increase to Hospice
Penalty
Summary
The facility failed to communicate with hospice representatives regarding an acute increase in blood glucose levels for a resident receiving hospice services. The resident, an elderly female with diagnoses including DM II, dementia, and anxiety, had a physician order to notify the MD if blood glucose levels were less than 70 or over 400. On a specific date, the resident's blood glucose level was recorded at 349, but this information was not communicated to the hospice nurse on call. The resident exhibited symptoms such as fatigue and increased thirst, which were not addressed by the attending nurse, who had not received a report from the night shift nurse and did not check the resident's vital signs that morning. Interviews with the hospice nurse, DON, and hospice NP revealed that the facility was expected to report any acute changes in condition, including significant changes in blood glucose levels. The hospice nurse indicated that such changes would prompt a review of the resident's file and potential adjustments to medication or insulin. The DON confirmed that charge nurses were trained to report acute changes and follow up with additional monitoring and reporting to the MD. However, the compliance nurse stated that the facility was only required to report glucose levels over 400, which contradicted the expectations set by other staff members and the hospice policy. This miscommunication and failure to report the resident's condition could lead to substandard care for residents receiving hospice services.
Failure to Report Allegations of Misappropriation and Neglect
Penalty
Summary
The facility failed to ensure that alleged violations involving neglect or mistreatment, including misappropriation, were reported immediately to the proper authorities. Resident #2 reported missing $400 from his wallet, but the facility did not report the incident to the state agency. Despite inconsistencies in Resident #2's account, the facility's failure to report the allegation of misappropriation to the state agency constitutes a deficiency. The Administrator, DON, and Social Worker were all aware of the incident but did not believe it warranted state notification due to the inconsistencies in the resident's story and the lack of evidence of theft. In another instance, LVN B reported to the Administrator that LVN A was neglecting Resident #6 by not conducting wound care as per physician orders. Resident #6, who has severe intellectual disability and cerebral palsy, developed wounds on her ankles that were initially documented as callouses. LVN D discovered the wounds and reported them as neglect. The Administrator and Regional Nurse investigated and suspended LVN A but did not report the incident to the state agency, concluding that the allegation was unsubstantiated. The facility's failure to report these allegations of misappropriation and neglect to the state agency within the required time frames could place all residents at risk. The facility's policies and state regulations mandate immediate reporting of such incidents, but the facility did not comply, leading to a deficiency in ensuring the safety and well-being of its residents.
Failure to Perform Prescribed Wound Care
Penalty
Summary
The facility failed to ensure that Resident #3 received wound care as prescribed, which could potentially lead to the deterioration of the wound. Resident #3, a male diagnosed with Diabetes Mellitus, was admitted to the facility on 10/26/23. His care plan included specific instructions for wound care to prevent and treat skin breakdown. However, on 03/13/24, the prescribed wound care for his left and right heels was not performed, as confirmed by multiple interviews and record reviews. The resident's wound care was supposed to be conducted every Monday, Wednesday, and Friday, but it was missed on the specified date, leaving the resident at risk of wound deterioration and infection. The failure to perform wound care was noted by the resident himself, who reported that the dressing still had the initials from the previous day, indicating that no new wound care had been administered. Interviews with various staff members, including LVNs, the NP, the Physician, and the Administrator, confirmed that the wound care was not performed as ordered. The staff acknowledged that not following the physician's orders could lead to the worsening of the resident's condition. The facility's policies on skin integrity management and skin assessment also emphasized the importance of performing wound care as ordered by the physician. Despite these policies, the wound care for Resident #3 was not conducted on the specified date, leading to a deficiency in the care provided to the resident.
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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