Golden Palms Rehabilitation And Retirement
Inspection history, citations, penalties and survey trends for this long-term care facility in Harlingen, Texas.
- Location
- 2101 Treasure Hills Blvd, Harlingen, Texas 78550
- CMS Provider Number
- 455672
- Inspections on file
- 31
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Golden Palms Rehabilitation And Retirement during CMS and state inspections, most recent first.
Exposed A-Bed Closet Clothing: The facility failed to ensure that 8 A-bed resident rooms had closet coverings or doors, leaving resident clothing exposed near the hallway. Staff reported the coverings had been removed during reconstruction, and interviews confirmed the closets had remained open for months without a covering. A resident said she did not want people looking at her things, and the facility could not provide a policy for a homelike environment.
The facility failed to notify the LTC Ombudsman of two resident discharges. One resident with UTI, weakness, cirrhosis, DM2, obesity, HTN, and sepsis was sent to the hospital, and another resident with CHF, PVD, and a pacemaker was discharged home; both had discharge plans and records showing no ombudsman notice. The SSD and ADM stated they were unaware the ombudsman had not been receiving discharge notifications, and the ombudsman reported no notices from the facility since 10/3/25.
A resident with CHF, acute respiratory failure, and COPD had stat verbal orders from an NP for a chest X-ray, EKG, and troponin communicated to the ADON. The ADON documented receipt of all three orders in a progress note but only entered the chest X-ray order, delegating entry of the EKG and troponin orders to the floor RN, contrary to facility practice that the person taking the verbal order must enter it. The DON and ADON acknowledged that this failure to immediately and completely enter the verbal orders into the medical record could delay necessary interventions and contribute to further deterioration in the resident’s condition.
A resident with peripheral vascular disease, bed confinement, and an existing heel pressure ulcer/DTI was sent to the ED for evaluation of a purple, non-open heel after an LPN obtained an order from a nurse practitioner and notified the charge LPN. The charge LPN reported calling the ED and arranging ambulance transfer but did not document the change in condition, the provider’s order, or the transfer in the medical record, stating she became busy and forgot. The other LPN did not document because she was not the assigned nurse. This resulted in an incomplete medical record that did not reflect the ED transfer or the associated order, contrary to facility policy and stated expectations for timely, accurate documentation.
The facility did not ensure that a registered nurse was present for at least 8 consecutive hours each day, as required. On multiple weekends, there was either no RN coverage or less than the required hours. Interviews revealed that only one RN regularly worked weekends, and RNs were not always present in the building. The DON and Administrator were unaware of the specific regulatory requirements, and the facility could not provide relevant staffing or scheduling policies.
Two residents with severe physical and cognitive impairments were assessed as dependent for ADLs and required a two-person assist for toileting, but their care plans and CNA electronic reports did not specify the required level of assistance. Staff interviews confirmed the omission, and facility policy mandates comprehensive care plans based on assessment findings.
A resident with multiple diagnoses and at risk for malnutrition did not receive prescribed liquid protein and Nepro supplements on numerous occasions because CMAs required clarification on the orders and did not obtain it, resulting in missed doses over several weeks. The lack of a clear process for resolving order clarifications contributed to the deficiency.
Two residents with end stage renal disease and documented dependence on dialysis were not accurately coded for dialysis in their MDS assessments, despite their medical records and care plans reflecting the need for this treatment. The omission was confirmed by the MDS nurse, and facility policy requires accurate documentation of such special treatments.
A resident with multiple complex medical conditions experienced a change of condition, including nausea, which was observed and reported by a speech-language pathologist to an LVN. The LVN acknowledged being informed and stated she notified the physician, but failed to document the change of condition or any follow-up actions in the medical record, resulting in incomplete documentation as required by facility policy.
A resident with multiple chronic conditions did not have a care plan that addressed her ongoing noncompliance with medical recommendations, such as not wearing heel protectors, refusing dialysis, and not following fluid and dietary restrictions. Staff and family were aware of these behaviors, but the care plan was not updated to include interventions or measurable objectives related to them, contrary to facility policy.
A resident with moderately impaired cognition eloped from a facility due to an unsecured exit door with a silenced alarm. The resident, who required assistance for mobility, was found by hospital security guards at a neighboring hospital. The facility failed to assess the resident's elopement risk and ensure the door alarm was functioning, leading to the resident's unsupervised departure.
A resident with a history of respiratory issues was observed receiving oxygen at 1L/min instead of the prescribed 3L/min. The nurse on duty was unaware of the correct setting and had not checked the concentrator during her shift. The facility's policy required reassessment of the oxygen flowmeter, which was not followed.
The facility failed to maintain proper temperature controls for medications in the black fridge, with temperatures recorded at 45 and 50 degrees Fahrenheit, outside the facility's policy range. Insulins and eye drops stored in the fridge require specific temperature conditions. Staff interviews revealed inconsistent monitoring and reporting of refrigerator temperatures, with night nurses responsible for checks but lacking follow-up verification by ADON and DON.
A resident with a stage four pressure ulcer did not receive proper wound care labeling, as an LVN failed to label the dressing with the date, time, and initials after treatment. This occurred twice during the same session, even after contamination. Interviews with the LVN and DON highlighted the importance of labeling for continuity of care, as per facility policy.
A resident with multiple health conditions did not receive a scheduled dose of the antibiotic Ceftriaxone due to its unavailability at the facility. The medication order was not processed in time, and there was a lack of clear responsibility and documentation among staff to ensure the medication was obtained. The facility lacked a formal policy for verifying medication availability, contributing to the deficiency.
A resident with no cognitive impairment was found with rubbing alcohol in his room, leading to alcohol poisoning and hospitalization. Despite initial removal of the substance by staff, the resident accessed it again, highlighting a failure in monitoring and enforcing non-permitted item policies.
A resident with a history of multiple health issues was found with altered mental status and a partially empty bottle of rubbing alcohol, which he admitted to drinking. The facility failed to report this incident within the required two-hour timeframe, leading to a delay in notifying the appropriate authorities. Interviews revealed confusion among staff regarding reporting responsibilities, contributing to the delay.
Exposed A-Bed Closet Clothing
Penalty
Summary
The facility failed to ensure that resident rooms 1201-A, 1202-A, 1205-A, 1207-A, 1209-A, 1211-A, 1213-A, and 1215-A had a covering or door on the closets for 8 of 19 resident A-Beds reviewed for environment. Observations from 04/13/26 through 04/15/26 showed that these A-bed closets, located adjacent to the hallway door, had no covering or door, leaving resident clothing exposed in the rooms. The report states that anyone entering the rooms could easily rub against the exposed clothing, and anyone passing by in the hallway could easily touch or remove it. During interview, Resident #19 said she did not like her closet open because she did not want people looking at her things. The OM said the open closet doors had been that way for a while and estimated the A-bed closets had been without doors for 2-3 months, adding that contractors were ordering doors and that temporary curtains would be placed until solid doors were installed. The DON said the A-bed closets had never been covered since she started in February 2025 and stated the clothing could be contaminated or removed by someone passing by in the main hallway. The ADM said the A-bed closet coverings had been removed in preparation for reconstruction, while staff also reported the curtains had been removed when reconstruction started and that no one questioned the exposed clothing. The facility was unable to provide a policy for a homelike environment.
Failure to Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to send copies of resident discharge notices to the representative of the Office of State Long-Term Care Ombudsman for 2 of 2 residents reviewed for discharge. One resident was discharged to the hospital after admission for urinary tract infection, muscle weakness, cirrhosis of the liver, type II diabetes mellitus with hyperglycemia, morbid obesity, hypertension, and sepsis. The resident’s MDS showed a BIMS score of 14, indicating intact cognition, and Section Q indicated a discharge goal to return to the community with active discharge planning already occurring. The care plan also reflected the resident’s wish to return home. Record review showed the resident was discharged to the hospital, but the electronic medical record contained no evidence that the LTC Ombudsman was notified of the discharge. During interviews, the SSD stated she had not been aware she needed to notify the ombudsman whenever a resident was discharged and said she later sent an email with names of residents discharged home since she started working at the facility. The SSD also stated she was not aware of the resident’s hospital discharge because it occurred before she began working at the facility, and the ADM stated she was not aware the ombudsman had not received discharge notifications since October 2025. The state managing local LTC Ombudsman stated she had not received any discharge notices from the facility since 10/3/25. A second resident, admitted with chronic systolic CHF, PVD, and a cardiac pacemaker, had an MDS discharge record showing independent cognitive skills and Section Q indicating the discharge plan was activated and already occurred for return to the community. The discharge summary showed the resident was discharged home, and the care plan documented the resident wished to return home with discharge goals to return home. The record contained no evidence that the LTC Ombudsman was notified of this discharge. The SSD and Administrator stated they were not aware the local ombudsman had not been notified of resident discharges, and the facility policy required the facility to notify the State LTC Ombudsman of discharges and, when a resident transferred with an expectation of returning could not return, that this constituted a discharge and the policy applied.
Failure to Properly Enter Verbal Stat Orders Into Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. A 74-year-old male resident with diagnoses including congestive heart failure, acute respiratory failure, and COPD had a quarterly MDS showing moderate cognitive impairment with a BIMS score of 8. On a specified date, the ADON documented in a progress note that she received new stat verbal orders from a nurse practitioner for a chest X-ray, EKG, and troponin. However, review of the physician’s orders for that date showed that the troponin and EKG orders were entered by RN A, while only the chest X-ray order was entered by the ADON. Interviews confirmed that the ADON was the person who took the verbal orders from the nurse practitioner and that facility practice was that the staff member who receives a verbal order is responsible for entering it into the resident’s record. The ADON stated she was acting as an extra set of hands and was not the resident’s nurse, and that she delegated entry of the troponin and EKG orders to RN A instead of entering them herself. The DON similarly stated that the ADON should have entered all three stat orders since she received them, and that orders should include the physician’s name, instructions, date, and time the order was given. Both the ADON and DON stated that not entering the order at the time of receipt could cause delays in treatment and may delay necessary interventions and potentially lead to further deterioration in the resident’s condition.
Failure to Document Hospital Transfer and Provider Order for Wound Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident who was at risk for pressure ulcers and had an existing unstageable heel pressure ulcer/deep tissue injury. The resident, an older female with peripheral vascular disease and bed confinement status, had a care plan identifying a pressure ulcer to the heel and interventions including immediate nurse notification of any new skin breakdown. On the referenced date, an LVN (LVN B) performed wound care, assessed the resident’s heel, and noted that it was purple but not open. LVN B contacted the nurse practitioner, who gave a new order to send the resident to the emergency room for further evaluation of the right heel wound, and LVN B then informed the charge nurse (LVN A) of this new order. According to interviews, LVN A stated that she called the emergency room to give report and that the resident was transferred via ambulance for evaluation of the right heel wound. However, LVN A acknowledged that she did not document in the resident’s medical record that the resident was transferred to the emergency room, stating she became busy with other residents and forgot to document the transfer and the physician’s order before the end of her shift, despite knowing documentation should have been completed. LVN B stated she did not document the change in condition because she was not the resident’s nurse and had informed LVN A, the charge nurse. The DON stated that the facility’s expectation is that documentation of changes in condition be timely, accurate, and completed in real time or before the end of the shift. Review of the facility’s documentation policy confirmed that cares provided are to be recorded in the electronic record each shift, but the resident’s record lacked documentation of the hospital transfer and the associated order for evaluation of the right heel wound.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, over a 90-day review period. Specifically, there was no RN coverage on several weekends, and on other weekends, RN coverage was less than 8 hours. Timesheet records confirmed these gaps in RN presence. Interviews with the Director of Nursing (DON) revealed that only one RN regularly worked weekends, and RNs assigned on weekends were not always present in the building unless called. The DON admitted to being unaware of the regulatory requirement for 8 consecutive hours of RN coverage daily and acknowledged it was her responsibility to ensure compliance. The Administrator also stated that ensuring RN coverage was ultimately her responsibility, despite having enough RNs on staff. Further, the facility was unable to provide requested policies regarding staffing, RN coverage, or scheduling, and only a job description for the DON was available. Both the DON and an RN interviewed recognized that certain tasks requiring an RN, such as signing off on baseline care plans, removing midline/PICC catheters, and pronouncing death, could not be performed without proper RN coverage. The lack of documented policies and inconsistent RN scheduling contributed to the deficiency.
Failure to Specify Toileting Assistance in Care Plans for Dependent Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, specifically omitting clear documentation regarding the level of assistance required for toileting. Both residents had significant physical and cognitive impairments, including muscle weakness, lack of coordination, dementia, and were assessed as dependent for activities of daily living (ADLs), requiring the assistance of two staff members for toileting. However, their care plans did not specify whether a one or two-person assist was needed for this task, and the electronic reports used by CNAs to guide care either omitted the toileting task or failed to indicate the required level of assistance. Observations and interviews revealed that CNAs relied on these electronic reports to determine the care needs of residents, especially when unfamiliar with them. In these cases, the reports did not provide the necessary information, and staff had to rely on their own experience or consult with charge nurses. The MDS-RN and DON both confirmed that the care plans and electronic reports did not reflect the two-person assist requirement for toileting, despite both residents being bed bound and fully dependent for this activity. The facility's policy requires the interdisciplinary team to develop comprehensive, person-centered care plans that include measurable objectives and timeframes based on comprehensive assessments. In these instances, the care plans did not meet this standard, as they failed to include specific instructions for toileting assistance, which was a critical need identified in the residents' assessments.
Failure to Administer Physician-Ordered Therapeutic Supplements Due to Lack of Clarification
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including cerebral infarction, type 2 diabetes, protein-calorie malnutrition, hypertension, anemia, peripheral vascular disease, and end stage renal disease on dialysis, was not administered prescribed therapeutic dietary supplements. The resident had documented risk factors for malnutrition, as evidenced by a low BMI and nutritional assessments indicating risk, and was ordered a renal diet with liquid protein and Nepro supplements by the physician. These orders were clearly documented in the resident's care plan and medication administration records (MAR). Despite the physician's orders, the resident did not receive the liquid protein and Nepro supplements on multiple occasions. Medication administration notes repeatedly indicated that certified medication aides (CMAs) did not administer the supplements due to needing clarification on the type or quantity of supplement to give. The CMAs documented their need for clarification and reported notifying nurses, but there was no evidence that clarification was obtained or that the supplements were subsequently administered as ordered. The MAR reflected numerous missed doses over several weeks. Interviews with the CMAs confirmed that they withheld administration of the supplements pending clarification, and that they notified nurses but were unsure if clarification was ever received. The Director of Nursing (DON) acknowledged that the lack of follow-up or miscommunication led to the failure to administer the supplements as ordered. There was no specific policy in place for how CMAs should escalate clarification needs to nurses and physicians, contributing to the ongoing issue.
Failure to Accurately Code Dialysis in MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of two residents who were receiving dialysis. For both residents, medical records and care plans documented diagnoses of end stage renal disease and dependence on renal dialysis. However, review of their MDS assessments showed that dialysis was not coded in section O, which is designated for special treatments, procedures, and programs. Interviews with the MDS nurse confirmed that dialysis was omitted from the MDS coding for both residents. The residents involved had significant medical histories, including conditions such as cerebral infarction, muscle weakness, diabetes, malnutrition, hypertension, anemia, peripheral vascular disease, chronic kidney disease, and end stage renal disease. Despite these documented needs and the presence of care plans addressing dialysis, the MDS assessments did not reflect the dialysis treatment. Facility policy and CMS guidelines require that special treatments and procedures be accurately documented in the comprehensive assessment, including the MDS.
Failure to Document Change of Condition in Resident Medical Record
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to document a resident's change of condition, specifically an episode of nausea, as required by facility policy and accepted professional standards. The resident, an elderly female with multiple complex diagnoses including stroke, diabetes, malnutrition, hypertension, anemia, peripheral vascular disease, and end stage renal disease on dialysis, was observed by a speech-language pathologist (SLP) to be different than usual, eating less, and reporting nausea. The SLP completed a 'stop and watch' form and reported the change to the LVN, who acknowledged being informed and stated she notified the physician, but did not recall if any new orders were given or if she documented the event. Review of the resident's medical record confirmed that there was no documentation by the LVN regarding the change of condition or any follow-up actions taken. Interviews with the SLP, the LVN, another nurse, and the Director of Nursing (DON) corroborated that the required documentation was missing. Facility policy mandates that all changes in a resident's medical or mental condition be documented, including details such as assessment data, notifications, and conversations with physicians. The failure to document this change of condition resulted in an incomplete medical record for the resident.
Failure to Develop Comprehensive Care Plan Addressing Resident Noncompliance
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including end stage renal disease, diabetes, heart failure, peripheral vascular disease, and arterial wounds. Although the resident's care plan addressed some medical needs such as renal failure, dialysis, and nutritional risks, it did not include interventions or measurable objectives related to the resident's specific behaviors that impacted her care. These behaviors included not offloading pressure from her feet, not wearing heel protectors, bearing weight against recommendations, refusing dialysis, consuming excess fluids and soda, and not following dietary restrictions. Staff interviews revealed that the resident frequently removed her heel protectors, sat up in her chair, requested ice despite fluid restrictions, and sometimes refused dialysis appointments. Staff and family education was provided regarding the importance of adhering to medical recommendations, but the care plan was not updated to reflect these ongoing behaviors or the interventions used to address them. The resident's family also brought in outside food that was not consistent with her prescribed renal diet, and staff documented these occurrences but did not incorporate them into the care plan. The facility's own policy required that the care plan identify any care or service declined by the resident, the associated risks, and the efforts made by the interdisciplinary team to educate the resident and her representative. However, the care plan did not document the resident's noncompliance or the facility's interventions to address these behaviors, resulting in a lack of guidance for staff and potential gaps in care coordination.
Resident Elopement Due to Unsecured Exit Door
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, leading to the elopement of a resident. The resident, who had moderately impaired cognition and required partial to moderate assistance for mobility, was able to exit the facility through an unsecured door. The door alarm was found to be silenced, which allowed the resident to leave unnoticed. The resident was later found by hospital security guards at a neighboring hospital. The incident occurred shortly after the resident was admitted to the facility, indicating that the facility did not adequately assess and address the resident's risk of elopement. The resident had no previous history of elopement, and staff were not aware of any wandering behavior. The failure to secure the exit door and ensure the alarm was functioning contributed to the resident's ability to leave the facility unsupervised. Interviews with staff revealed that the alarm system for the exit door had been silenced, possibly by an IT person servicing the system days before the incident. Staff were not aware of the resident's elopement until a medication aide noticed the resident was missing during a routine check. The facility's lack of immediate response and failure to maintain a secure environment placed the resident at risk of harm.
Removal Plan
- Head to Toe Assessment completed
- Notification of MD
- Notification of RP
- Clinicians initiated and completed 100% re-evaluations for elopement risk and no other new residents were identified as medium to high risk. All new admissions to be reviewed by DON/designee and LN staff educated/inserviced to notify DON/designee of any new admissions flagging medium to high risk on UDA.
- In-service on Abuse and Neglect and Elopement initiated and completed
- 100% of resident head count was conducted by licensed nurses at time of incident and all active residents accounted for and Facility initiated 100% of head count qshift. 100% Head count will continue 3xW 2nd shift
- East exit door sound activated on door resident used to elope through.
- Maintenance director tested all doors with alarms to ensure alarm sounds at in working order. Maintenance director/designee will test alarm sounds 3xW for working order.
- Alert system placed to residents left wrist
- Elopement drills initiated and continued. Elopement drills will be conducted 2xW for both 1st and 2nd shift for a period of 2 weeks
Failure to Administer Correct Oxygen Setting
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care received oxygen therapy at the correct setting as ordered by the physician. The resident, who was cognitively intact and had a history of acute and chronic respiratory failure with hypoxia, bronchiectasis, and idiopathic pulmonary fibrosis, was observed receiving oxygen at 1 liter per minute instead of the prescribed 3 liters per minute. This discrepancy was noted during an observation, and the resident did not exhibit signs of respiratory distress at that time. The nurse responsible for the resident's care was unaware of the correct oxygen setting and had not checked the oxygen concentrator during her shift. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that it was the responsibility of the floor nurse to verify the oxygen settings, and that training on oxygen administration was provided upon hire and annually. The facility's policy required reassessment of the oxygen flowmeter for correct liter flow, which was not adhered to in this instance.
Improper Medication Storage Temperature Control
Penalty
Summary
The facility failed to maintain proper temperature controls for medications stored in one of its medication storage refrigerators, specifically the black fridge. During an observation, the temperature inside the black fridge was recorded at 45 degrees Fahrenheit and later at 50 degrees Fahrenheit, which was outside the facility's policy range. This fridge contained insulins and eye drops, which require specific temperature conditions to remain effective. The temperature log indicated that the temperature should be between a specified range, and any deviation should be reported immediately to a supervisor. Interviews with staff revealed a lack of consistent monitoring and reporting of refrigerator temperatures. LVN D stated that night nurses were responsible for checking the temperatures, and if the temperature was outside the recommended range, the medications could expire. LVN E admitted to not checking the black fridge on a particular day because it was already marked as checked by another nurse. The ADON and DON also confirmed that night nurses were responsible for temperature checks, but there was a lack of follow-up verification. The ADON was unsure of the protocol for handling out-of-range temperatures due to being in training. The facility's policy required medications to be stored according to manufacturer recommendations, and any expired or deteriorated medications should be removed immediately.
Failure to Label Wound Dressings in Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with pressure ulcers, leading to a deficiency in quality of care. Specifically, a resident with a stage four pressure ulcer on the sacral area did not receive proper wound care labeling during treatment. The resident, who had severe cognitive impairment and multiple medical conditions including cerebral infarction and osteoarthritis, was observed receiving wound care from an LVN who did not label the dressing with the date, time, and initials after completing the treatment. This omission occurred twice during the same treatment session, even after the dressing was contaminated and replaced. Interviews with the LVN and the Director of Nursing (DON) revealed that labeling the dressing is a critical step in the wound care process to ensure continuity of care and prevent the worsening of the wound. The facility's policy and skills checklist also emphasized the importance of labeling wound dressings. The failure to label the dressing could lead to inadequate treatment and potential worsening of the resident's condition, as it is the only way for staff and physicians to know when the dressing was last changed.
Failure to Ensure Timely Availability of Antibiotic for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically by not ensuring the availability of a physician-ordered antibiotic, Ceftriaxone sodium, for a resident on the scheduled date. The resident, a male with a history of acute respiratory failure, diabetes, hypertension, acute kidney failure, and a urinary tract infection, was admitted to the facility and had an order for Ceftriaxone to be administered at 4:00 PM on a specific date. However, the medication was not available at the facility at the scheduled time, and the nurse documented that the medication was not in the facility and faxed the information to the pharmacy. Interviews with various staff members, including nurses and pharmacy personnel, revealed a lack of clarity and responsibility regarding the process for ensuring that newly admitted residents have their medications available as ordered. The admitting nurse and subsequent shifts were responsible for ensuring the availability of the medication, but there was no clear documentation or evidence that the necessary steps were taken to obtain the medication in a timely manner. The pharmacy received the order the following day and sent the medication STAT, but it was not delivered until after the scheduled administration time. The Director of Nursing (DON) and Clinical Resource personnel acknowledged the importance of ensuring residents receive their medications as scheduled to avoid adverse health impacts. However, there was no documented policy or procedure in place for verifying the availability of residents' medications, and it was noted that the process was more of an informal procedure provided during staff orientation. The lack of a formal policy and clear documentation contributed to the failure to provide the necessary pharmaceutical services for the resident.
Failure to Prevent Access to Hazardous Substances
Penalty
Summary
The facility failed to maintain a safe environment for Resident #1, who was found with rubbing alcohol in his room, leading to an incident of alcohol poisoning. On the morning of 06/19/24, Medical Records staff discovered two bottles of rubbing alcohol in Resident #1's room, which were accessible to him. Despite removing these bottles and informing a family member that such items were not allowed, later that day, the Assistant Director of Nursing (ADON) found Resident #1 with altered mental status and a partially empty bottle of rubbing alcohol. This incident resulted in Resident #1 being sent to the emergency room for evaluation and treatment. Resident #1, a male with a history of pulmonary hypertension, endocarditis, type 2 diabetes, end-stage renal disease, and nicotine dependence, was admitted to the facility with no cognitive impairment as indicated by a BIMS score of 14. Despite this, the facility did not adequately monitor or restrict access to hazardous substances, as evidenced by the presence of rubbing alcohol in his room. The resident admitted to drinking the rubbing alcohol with the intention of getting drunk, which led to his hospitalization for alcohol poisoning. Interviews with facility staff revealed a lack of consistent monitoring and enforcement of policies regarding non-permitted items. The Medical Records staff and ADON were aware of the regulations but failed to prevent the re-entry of rubbing alcohol into Resident #1's environment. The facility's procedures for checking and inventorying residents' belongings upon admission were not effectively implemented, as Resident #1's inventory sheet did not list rubbing alcohol, and staff were unaware of its presence until the incident occurred.
Failure to Timely Report Alleged Abuse Involving Rubbing Alcohol Ingestion
Penalty
Summary
The facility failed to report an alleged violation involving a resident who was found with altered mental status and a partially empty bottle of rubbing alcohol within the required two-hour timeframe. The incident occurred when the resident was discovered with a 1/4 empty bottle of rubbing alcohol and exhibiting signs of altered mental status. Despite the urgency of the situation, the facility did not report the incident to the appropriate authorities until more than two hours after the discovery. The resident involved was a male with a history of pulmonary hypertension, endocarditis, type 2 diabetes mellitus, peripheral vascular disease, end-stage renal disease, and nicotine dependence. He was initially admitted to the facility with no cognitive impairment, as indicated by a BIMS score of 14. The resident was found with rubbing alcohol, which he reportedly used for his dry legs, and later admitted to drinking it in an attempt to get drunk. This led to his hospitalization for alcohol poisoning. Interviews with facility staff revealed a lack of clarity and adherence to the reporting protocol. The ADON was informed of the situation by the dialysis center and assessed the resident, but the report to the state agency was delayed. The Interim Administrator/Clinical Resource, responsible for reporting, did not act within the two-hour window, citing hearsay information as a reason for the delay. This failure to report promptly could have placed residents at risk for undetected abuse, neglect, and a decline in their sense of safety and well-being.
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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