Grace Pointe Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 2301 N Oregon St, El Paso, Texas 79902
- CMS Provider Number
- 675106
- Inspections on file
- 39
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Grace Pointe Wellness Center during CMS and state inspections, most recent first.
Failure to maintain resident dignity during grooming and privacy care: A cognitively intact female resident with multiple psychiatric and neurologic diagnoses was observed with unwanted facial hair and said staff had not offered shaving assistance, while staff acknowledged shaving should have been addressed during ADL care. Another resident with dementia and bilateral leg amputations was repeatedly observed without bottoms, with his genitalia and anus visible from the room entrance and through an open curtain, and staff stated he had refused clothing or covers and that the behavior had not been documented or care planned.
Unqualified Activities staff directed resident activities. The Activities Assistant was the only person in the Activities dept and independently led an activity with 14 residents while not holding the required Activity Director certification. Interviews with the HR Coordinator, Activities Assistant, Administrator, and DON confirmed the Activities Director position was vacant, the Assistant was performing Director duties, and the job description required a certified Activity Director.
Improper Cooling and Refrigeration of Leftover Oatmeal: Dietary staff placed leftover oatmeal from breakfast directly into a refrigerator while it was still hot. The oatmeal was observed covered in a steam table pan on the bottom rack of refrigerator #1, and the DS, DON, and Administrator stated it should have been cooled before refrigeration. Facility policy required leftovers to be cooled properly, including using shallow pans on ice, before being stored.
Inoperable Laundry Dryer Not Maintained: A laundry dryer was found rusted, dusty, missing its operational panel, and non-responsive while 2 other dryers were in use. Laundry staff confirmed the unit had been out of service for about a year, and leadership stated they knew it was broken but had no intention of fixing or replacing it because the current census did not require it. Staff also reported no formal in-service or documented process for reporting faulty equipment, and the facility did not provide a policy on equipment maintenance or reporting.
A resident with dementia, severe cognitive impairment, and ADL deficits was observed asleep in bed with the call light looped around another call light hanging from the wall, leaving it out of reach. The DON, RN, and CNA stated call lights should be within reach so residents can make needs known, and the DON stated the facility did not have a policy regarding call lights.
Failure to provide needed fingernail care: A resident with multiple psychiatric and neurologic diagnoses who required substantial to total assistance with ADLs was observed with long, dirty fingernails despite a care plan calling for staff help with grooming and hygiene. The resident said she wanted her nails trimmed and had not been offered assistance, while staff stated hygiene caregivers were responsible for checking and trimming nails during care. The DON said she did not see harm, but the record did not show a refusal for nail trimming.
Improper Storage of Oxygen Nasal Cannula: A resident with COPD and an order for O2 at 3 L/min via NC had the tubing left exposed on the bed while not in use. The DON said the tubing should be stored in a plastic bag, while RN E and a CNA stated it should be kept bagged and dated to prevent contamination; the facility policy stated the resident will be free from infection.
Pest Control Program Not Maintained in Dining Area: A live cockroach was observed in the dining room, along with a dead cockroach in the dining room and 5 dead cockroaches in the air conditioning unit room. The Activities Assistant did not remove the live cockroach herself and left it until residents exterminated it, while interviews showed staff relied on monthly pest control services, had no policy for handling live pests, and had not received pest control training.
Survey results binder not readily accessible: The facility failed to keep the annual survey results binder in an easily accessible location for residents, family members, legal representatives, and the public. The Administrator stated the binder had been kept in her office bookshelf before being moved to the receptionist desk area, while the Receptionist did not know where it belonged and residents reported they did not know where to find it or the significance of its contents.
A resident with a history of lupus and intact cognition experienced inconsistencies in the administration and documentation of Acetaminophen with Codeine for pain management. Although physician orders allowed for 2 tablets as needed, records showed only 1 tablet was dispensed at times, and documentation on the EMAR and Narcotic Count Sheet did not match. Nursing staff interviews confirmed required procedures for medication checks and documentation were not consistently followed, resulting in inaccurate records.
A facility with 154 beds did not employ a qualified full-time social worker after the previous social worker resigned, and a replacement only worked for about a week before also resigning. The Administrator confirmed that no interim support was sought from other company facilities, resulting in a gap in social services coverage for residents' psychosocial and discharge planning needs.
A resident with multiple medical conditions filed grievances related to maintenance and activities, but the facility failed to document resolutions or provide written decisions as required. Staff interviews and record reviews revealed incomplete grievance forms and a lack of follow-through, with several grievances over multiple months lacking evidence of resolution or communication to the resident.
The facility did not complete the required annual Employee Misconduct Registry and Nurse Aide Registry screenings for an LVN, as mandated by its abuse prevention policies. This oversight resulted in a lapse in the implementation of procedures designed to prohibit and prevent abuse, neglect, and exploitation.
A facility failed to send a required discharge notice to the local Ombudsman when a resident was issued a facility-initiated discharge for non-payment of a private room. Although the discharge notice stated that a copy had been sent, interviews and record review confirmed that the Ombudsman did not receive the notice as required. The resident had multiple medical conditions and required 24-hour nursing care.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with moderate cognitive impairment and significant physical disabilities reported sexual abuse by a CNA during personal care. Despite the disclosure to multiple staff members, the allegation was not investigated, the alleged perpetrator was not suspended, and the incident was not reported to law enforcement or the State Agency as required. The only action taken was to restrict male staff from caring for the resident, with no documentation or escalation to the Administrator, resulting in a serious breakdown of abuse prevention protocols.
A resident with moderate cognitive impairment reported to staff that a CNA had sexually abused him during a shower, but the allegation was not immediately reported to the administrator or law enforcement as required. Staff communicated the allegation among themselves, but confusion over reporting responsibilities led to a lack of documentation and delayed action. The accused CNA continued working until the incident was discovered by surveyors, revealing a breakdown in the facility's abuse reporting protocol.
A resident with vascular dementia and moderate cognitive impairment alleged inappropriate sexual contact by a CNA during bathing. The incident was not promptly or properly reported, documented, or investigated, and the alleged perpetrator continued working in the facility with access to other residents. Staff interviews revealed confusion and inconsistent adherence to abuse reporting protocols, and required documentation and administrative notification were lacking.
A resident with moderate cognitive impairment and a history of vascular dementia, hemiplegia, and hemiparesis had a documented preference for no male CNAs in their room following an allegation of sexual abuse. This preference, noted in a social services assessment, was not included in the resident's care plan, and staff were inconsistently aware of the instruction. The facility failed to document or communicate the resident's preference, resulting in a lack of a comprehensive, person-centered care plan.
A resident with moderate cognitive impairment and multiple medical conditions reported being inappropriately touched by a CNA during a shower. Although the allegation was communicated among staff, there was no documentation of the incident in the resident's medical record or facility reports, contrary to facility policy and accepted standards.
The facility failed to provide residents with reasonable access to a telephone and a private place to make calls without being overheard. A resident was observed using a phone at the nurses' station, compromising privacy. The chapel phone, intended for private use, was non-functional due to construction. Staff and residents confirmed the lack of privacy, with some residents feeling embarrassed. The facility's policy on resident rights to privacy was not followed, and some staff were unaware of the need for privacy during phone calls.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in their care. One resident with diabetes and peripheral vascular disease was not seen by a podiatrist, resulting in long, yellow, and chipped toenails. Another resident with severe cognitive impairment and dementia exhibited wandering behavior that was not addressed in her care plan. The facility's lack of proper documentation, communication, and follow-up contributed to these deficiencies.
Two residents in the facility did not receive proper foot care, leading to deficiencies in maintaining their foot health. One resident with diabetes and peripheral vascular disease had overgrown and discolored toenails due to a lack of timely podiatry services. Another resident with severe cognitive impairment also had long, thick, and discolored toenails, with no recent podiatrist visit. The facility's policy required regular foot assessments and podiatrist referrals, but there was a breakdown in communication and documentation, resulting in inadequate care.
The facility failed to maintain clean oxygen concentrator filters for two residents, both with respiratory conditions, by not adhering to weekly cleaning protocols. The filters were found dirty, and the orders for cleaning had been discontinued without proper documentation. Staff interviews revealed a lack of clear responsibility for maintaining the filters, contrary to facility policy and manufacturer guidelines.
The facility failed to ensure proper pharmaceutical services, including accurate reconciliation of controlled substances, proper medication storage, and updating medication labels following physician order changes. Observations revealed issues such as incomplete documentation of controlled substance counts, improper storage of liquid medications, and failure to update medication labels, posing risks of drug diversion and incorrect medication administration.
The facility did not refrigerate an opened bottle of Acidophilus Probiotic Dietary Supplement as required, found on a Medication Aide's cart. LVN B confirmed the manufacturer's label instructed refrigeration after opening and removed the bottle. This oversight could impact medication efficacy and availability.
The facility failed to maintain proper food storage and sanitation procedures, as observed during a survey. Foods were not stored in sealed containers, and the kitchen had maintenance issues such as missing ceiling tiles and lint-covered vents. The Three-Compartment Sink Procedures were not followed, with staff not immersing items in sanitizer for the required time. The facility's dietary services policy, which outlined proper food storage and equipment sanitation, was not adhered to, potentially risking foodborne illnesses.
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper hand hygiene practices during meal service and inadequate storage of medical supplies and personal belongings. An LVN did not perform hand hygiene after repositioning a resident, and open medical supplies were found on a treatment cart. Personal items were stored on a clean linen table shelf, contrary to facility policy, increasing the risk of cross-contamination.
The facility failed to maintain a safe and functional environment, as several resident rooms had closet doors off their tracks, lacking necessary guides, posing potential injury risks. Observations and interviews revealed a lack of communication and awareness among staff, with the Maintenance Supervisor confirming the hazard. The facility's policy emphasizes a safe environment, yet the current state of the closet doors indicates a deficiency.
A resident with severe cognitive and physical impairments was found without a reachable call light, contrary to their care plan. Staff interviews revealed a lack of communication and adherence to the care plan, as the resident could not use a regular call light due to hand contractures. The facility lacked a call light policy, contributing to the deficiency.
A resident reported that a nurse entered his room without permission while he was naked, leading to feelings of embarrassment and a loss of dignity. The facility's policy requires staff to knock and wait for permission before entering, but the grievance remained unresolved.
A resident received an opened letter from a family member, violating their right to privacy. The Business Office staff admitted to routinely opening mail unless residents were on a specific list. Despite a policy to deliver unopened mail, the facility failed to consistently follow this protocol, leading to a grievance filed by the resident.
The facility failed to prevent abuse when a resident verbally threatened another resident in the morning, which was not reported or investigated. Later that day, the same resident physically assaulted the other in the dining room. Both residents have histories of aggressive behavior and cognitive impairments, but the facility did not adequately monitor or protect them, leading to the altercation.
The facility failed to implement policies to prevent abuse, neglect, and exploitation, leading to a physical altercation between two residents. An earlier verbal threat was not reported or investigated, and both residents' care plans were not effectively followed, resulting in inadequate protection and monitoring.
The facility failed to report an altercation between two residents, where one resident physically assaulted another. The incident was not reported to the Administrator, putting residents at risk of injury. Both residents had histories of aggressive behavior and cognitive impairments, but the facility did not follow its abuse prevention and reporting protocols.
A resident with dementia exhibited ongoing wandering behaviors that were not adequately tracked or addressed by the facility. Despite being identified as at risk for wandering, the resident's care plan lacked specific interventions, placing him at risk of harm. Medical records and staff interviews revealed inconsistent monitoring and a lack of proper assessment of the resident's behaviors.
Failure to Maintain Resident Dignity During Grooming and Privacy Care
Penalty
Summary
The facility failed to treat residents with respect and dignity for 2 of 8 residents reviewed for dignity. One resident, a 69-year-old female with diagnoses including morbid obesity, schizoaffective disorder, unspecified psychosis, bipolar disorder with manic episode and psychotic features, major depressive disorder, Parkinson’s disease, generalized muscle weakness, anxiety disorder, delusional disorder, and personality disorder, had a BIMS score of 14 and was able to make decisions regarding daily activities. Her care plan addressed ADL and self-care deficits and included staff assistance with bathing, shaving, and personal hygiene tasks. During observation on 03/10/2026, she was noted to have long facial hair on her shin, and she stated she would have liked to be shaved but staff had not offered assistance. She also stated she did not ask because she felt she was bothering staff. A review of interviews showed multiple staff members stated CNAs and other staff assisting with ADLs were responsible for checking hygiene and offering shaving assistance if the resident desired it. Staff stated that not assisting a female resident with unwanted facial hair could leave her embarrassed, ashamed, ignored, or feeling that staff did not care about her wellbeing. The DON stated she did not see harm with the resident having long facial hair and said the resident had been refusing ADLs, showers, and medications, but the progress notes did not show refusals of ADLs for shaving her facial hair. The Administrator stated any staff member who had contact with the resident should have asked if she wanted assistance with shaving her facial hair. The facility also failed to maintain the dignity of another resident with bilateral leg amputations and dementia without behavioral disturbance. This resident had a BIMS of 07 and was documented as having inattention, disorganized thinking, altered level of consciousness, and a need for assistance with personal care. During observation and interview, he was seen without bottoms, with his genitalia visible during the interview, and later his anus and genitals were visible from the entrance of his room while the privacy curtain was open or not in use. Staff stated he had been resistant to care and had refused to wear bottoms or covers, and one LVN stated staff would not intervene if he chose to remain bottomless in his room. The DON stated the behavior needed to be care planned and documented, and the Administrator stated it was not acceptable for residents to be exposed because it was a dignity issue.
Unqualified Activities Staff Directed Resident Activities
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional, and the Activities Assistant had not completed State approved training to direct facility activities. During an interview, the Receptionist stated the Activities Assistant was the only individual in the Activities department. During an observation, the Activities Assistant independently led an activity with 14 residents present, involving physical stretching, meditation, and prayer. During interviews, the HR Coordinator stated the activities department consisted of one Activities Assistant and a part-time assistant, and that the Activities Director position had been vacant since 2/20/2026. She stated the Activities Assistant would transition into the Activities Director position once she passed her certification course, and that the Administrator oversaw the operation and helped with the monthly calendar and supplies. The HR Coordinator also stated she was responsible for reviewing employee licenses and certifications, but was unaware of any policy requiring the Activities Assistant to possess a certificate. The Activities Assistant stated she did not have certification to be an Activity Director and described responsibilities that included conducting activities, transporting residents to and from activities, providing in-room activities, and ensuring residents did not fall during activities. She stated the previous Activities Director had resigned about 2 weeks earlier and that she was completing the activities calendar going forward. The Administrator stated the Activities Assistant had a conditional offer for the Activities Director position but did not currently possess the required certificate, and the DON stated the Activities Assistant had been facilitating activities with instruction from the regional Activities Director. Record review showed the Activity Assistant job description reported directly to the Activity Director, and the Activity Director job description stated the position must be a certified Activity Director.
Improper Cooling and Refrigeration of Leftover Oatmeal
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food service standards when dietary staff placed a steam table pan of oatmeal directly into refrigerator #1 while it was still hot. During an observation in the kitchen, the oatmeal was found stored on the bottom rack of the refrigerator, covered with plastic wrap, and was hot to the touch at the time of storage. The report identified this as a failure in proper cooling and storage of prepared food in 1 of 1 kitchen reviewed for sanitation and food storage. During interviews, the [NAME], DS, DON, and Administrator all stated that hot oatmeal should have been cooled before refrigeration and that placing hot food into the refrigerator could raise the unit’s internal temperature and affect other stored food items. The DS stated the oatmeal should have been cooled by placing it over ice before being stored. Record review of the Dietary Services Policy and Procedure Manual, titled Left-Over Foods, stated leftover foods must be refrigerated, dated, labeled, and properly covered promptly after meal service, and that large quantities of food must be cooled in shallow pans on ice, reaching 70 degrees within 2 hours and 41 degrees or below within 4 additional hours. In interview, it was stated the oatmeal was leftovers from breakfast and that it was placed in the refrigerator by staff.
Inoperable Laundry Dryer Not Maintained
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition when the furthest right dryer in the laundry room was found non-operational. During observation, Laundry Aide I was using 2 of 3 dryers, and the third dryer was rusted, dusty, missing its operational panel, and did not respond when the knobs were moved and power was checked. Laundry Aide I confirmed the dryer had not worked for approximately a year and stated she had not received training or in-service on reporting broken equipment. She also stated that the dryer’s lack of operation could delay cleaning sheets, towels, Hoyer nets, personal clothing, and other laundry items. Interviews with the Laundry Supervisor, Maintenance Supervisor, and Administrator showed all were aware the dryer was broken, with the Laundry Supervisor stating he had known since January and the Administrator stating she had known for 3 months. The Laundry Supervisor stated the facility had no intention of fixing or replacing the dryer because the current census did not require more than 2 dryers, and he had no concern about having inoperable equipment in the laundry room. The Maintenance Supervisor stated records from his predecessor showed the dryer was not fixable and would require replacement, and the Administrator stated the dryer was to be removed after the surveyors’ exit. A requested policy on reporting faulty equipment or maintaining equipment was not provided.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that Resident #10’s call light was within reach. Resident #10 was an [AGE]-year-old male with an admission date of 04/07/2023 and a readmission date of 12/12/2024. His history and physical dated 10/07/2025 listed dementia, and his quarterly MDS showed a BIMS score of 02, indicating severe cognitive impairment. Section GG showed he needed supervision or touching assistance for toileting, and the care plan revised on 02/16/2026 identified an ADL self-care performance deficit related to clinical illness myopathy, weakness, and sarcopenia, with interventions for 1 staff assist for bed mobility and toilet use. During an observation on 03/10/2026 at 10:04 a.m., Resident #10 was asleep in bed and the call light was looped around another call light that was hanging from the wall. In interviews, the DON, an RN, and a CNA stated that the call light was meant for the resident to make needs known, that it should be within reach, and that all staff were responsible for ensuring it was properly placed during rounds. The DON stated the facility did not have a policy regarding call lights.
Failure to Provide Needed Fingernail Care
Penalty
Summary
The facility failed to ensure a resident who was unable to complete activities of daily living received needed assistance with grooming and personal hygiene, specifically fingernail care. Resident #2 was a 69-year-old female admitted to the facility with diagnoses including morbid obesity, schizoaffective disorder, unspecified psychosis, bipolar disorder with manic episode and psychotic features, major depressive disorder, Parkinson’s disease, generalized muscle weakness, anxiety disorder, delusional disorder, and personality disorder. Her MDS admission assessment showed a BIMS score of 14, indicating she was cognitively intact and able to communicate her needs and preferences. The assessment also showed she required substantial to maximal assistance with showering and was dependent for toileting hygiene, lower body dressing, and putting on and taking off footwear. The care plan identified that she required assistance with bathing and personal hygiene and included interventions for staff to monitor and assist with grooming tasks and maintain hygiene needs, including routine nail length and nail hygiene as part of regular personal care. During an observation and interview, Resident #2 was found with long fingernails measuring about one inch in length. Her nails appeared yellowish, and dark particles and debris were observed underneath them. She stated she had been at the facility for about a month, wanted her fingernails trimmed, and said staff had not offered assistance. She also stated she did not like having long fingernails because she scratched herself and had cut herself in the past. Interviews with nursing and other facility staff showed that staff who assisted residents with hygiene were responsible for checking fingernails and asking whether trimming was needed, typically during showers or hygiene care. Staff stated that if a resident refused nail trimming, it should be documented in progress notes. The DON stated she did not see harm with the resident having long fingernails and said the resident had been refusing ADLs, showers, and medications, but the facility’s progress notes did not show refusals of ADLs for nail trimming. The facility’s Nail Care policy stated nail management includes cleansing, trimming, smoothing, and cuticle care, is usually done during the bath, and should be performed regularly and safely to keep the resident free from abnormal nail conditions and infection.
Improper Storage of Oxygen Nasal Cannula
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #18 by not ensuring the resident’s nasal cannula was properly stored when oxygen was not in use. Resident #18 was a male admitted on 06/06/2025 with a history of COPD, a BIMS score of 09 indicating moderate cognitive impairment, and an order for oxygen at 3 liters per minute via nasal cannula related to COPD. His care plan included interventions to give oxygen therapy as ordered by the physician. During an observation in the resident’s room, the nasal cannula was found left exposed on the bed while the resident was not in the room. The DON stated the oxygen tubing was to be stored in a plastic bag when not in use, but she did not see an issue with the cannula being left exposed on the bed. RN E stated the tubing and nasal cannula were to be kept in a plastic bag with a date and that exposed tubing needed to be changed because it could be contaminated. CNA D also stated the nasal cannula should be stored in a plastic bag while not in use. The facility policy titled Oxygen Administration stated the resident will be free from infection.
Pest Control Program Not Maintained in Dining Area
Penalty
Summary
The facility failed to maintain an effective pest control program and was not free of pests and rodents in 1 of 1 dining rooms reviewed. During an observation on 3/11/2026 at 11:05 AM, a live cockroach was found in the dining room and was acknowledged by the Activities Assistant. A dead cockroach was also found between the wall and the furniture table in the dining room near the air conditioning unit, and 5 additional dead cockroaches were found inside the air conditioning unit room to the right of the doorway. During the same observation, the Activities Assistant passed out coffee and stepped over the cockroach at 11:28 AM. Residents sitting in the dining room exterminated the cockroach at 11:37 AM, and it was left at the table side by the Activities Assistant. In an interview on 3/12/2026, the Activities Assistant stated she did not exterminate the cockroach herself because she had a phobia of cockroaches and had not received training on pest control. She stated she notified the HR Coordinator to have housekeeping pick up the dead cockroach and disinfect the floor, and she suspected the cockroaches were coming from the air-conditioning room. Interviews with the LVN, Maintenance Supervisor, administrator, and DON showed the facility relied on monthly pest control services and had no policy in place for staff handling live pests. The administrator stated staff were expected to kill a cockroach immediately, dispose of it, and document it in the pest control book, while the DON stated staff should remove it immediately, perform hand hygiene, and document it in the pest control binder. Record review showed repeated pest control invoices for American cockroach and German cockroach treatment from 6/18/2025 through 3/12/2026, and the facility policy stated it would maintain an effective pest control program to provide an insect-free and vermin-free food service department.
Survey Results Binder Not Readily Accessible
Penalty
Summary
The facility failed to ensure residents had the right to examine the results of the most recent survey and failed to post the most recent survey results in a place readily accessible to residents, family members, legal representatives, and the public. During an observation on 03/11/2026 from 11:27 AM to 11:55 AM, the annual survey results binder could not be located in an easily accessible area on the ground floor, 2nd floor, or 3rd floor. At 11:56 AM, the Administrator was observed placing the binder in the receptionist desk area. The Administrator stated the binder had been on her bookshelf inside her office before being moved and acknowledged that the bookshelf was not an easily accessible location. She also stated residents and visitors should not have to ask for the binder and that they would not have readily access to past survey results and corrections made by the facility. During interviews, the Receptionist stated she had worked at the facility for a month, had not received training or knowledge about the binder, and did not know where it needed to be placed. LVN G stated the binder was in the receptionist desk area and that if it were in the Administrator's office it would be a problem for accessibility because it would require staff assistance to locate it. CNA H stated the survey results could be in the office of the DON or Administrator and that he did not know the exact location. In a confidential group interview, 10 out of 10 residents denied knowing where to locate the annual survey results binder and denied knowing the significance of its contents. A policy on survey binder results was requested from the DON, but the facility did not provide one.
Failure to Accurately Document and Administer Controlled Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for one resident. Specifically, there was a discrepancy between the physician's orders for Acetaminophen with Codeine and the documentation on the resident's Electronic Medication Administration Record (EMAR) and Narcotic Count Sheet. The physician's orders were updated to allow for 2 tablets every 6 hours as needed for pain, but the Narcotic Count Sheet indicated that only 1 tablet was pulled and administered on several occasions, while the EMAR reflected administration of 2 tablets. Interviews with staff confirmed that only nurses were to administer and document narcotic medications, and that procedures required immediate and accurate documentation on both the EMAR and Narcotic Count Sheet. However, inconsistencies in documentation and administration were identified, with staff unable to explain the discrepancies. The resident involved had a history of Systemic Lupus Erythematosus and was cognitively intact, with a care plan addressing the need for pain management. The resident reported receiving 1-2 tablets at different times and was unaware of the reason for the variation. Staff interviews revealed that nurses were trained to perform medication checks and document administration, but there was uncertainty regarding the monitoring frequency of narcotic counts by the DON. Facility policy required immediate documentation of controlled medication administration, but this was not consistently followed, leading to inaccurate records for the resident's pain medication.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility, licensed for 154 beds, failed to employ a qualified social worker on a full-time basis as required for facilities with more than 120 beds. According to the facility census, there were 54 residents at the time of the survey. The Administrator confirmed during interview and record review that the previous social worker resigned about a month prior, and a replacement hired on 08/29/25 only worked for approximately one week before resigning for personal reasons. As of the time of the survey, the facility had just hired another social worker, scheduled to start on 10/07/25, leaving a gap in social work coverage. The Administrator also stated that, despite the company operating multiple facilities in town, he had not reached out for assistance with social services during this period. The facility's policy requires a social worker to manage psychosocial needs, grievances, and discharge planning, but these responsibilities were not fulfilled due to the absence of a qualified full-time social worker. This failure was identified through interviews and record reviews conducted by surveyors.
Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were resolved and that written decisions were issued, as required by policy. One resident, who was cognitively intact and had multiple medical diagnoses including GAD, bipolar disorder, DM2, HTN, CHF, and lupus, filed grievances regarding maintenance issues with her television and concerns about activities being conducted primarily in Spanish. Documentation revealed that the grievances were not fully addressed, with key sections of the grievance forms left blank, including the summary of findings, recommendations, actions taken, and the method of notifying the resident of the resolution. Record review of the facility's grievance binder showed a pattern of incomplete documentation, with several grievances in July, August, and September lacking evidence of resolution. Interviews with staff, including the Activities Director, Maintenance Assistant, Maintenance Director, and Administrator, confirmed that the grievances were not fully investigated or resolved. Staff acknowledged communication barriers and delays in addressing the resident's concerns, such as the lack of compatible TV remotes and the absence of cable service in the resident's room. The Administrator was aware of the unresolved issues but had not provided documentation of corrective actions or written decisions to the resident. The facility's grievance policy requires prompt efforts to resolve grievances and mandates that written decisions be issued to residents, including details such as the date received, summary of the grievance, investigative steps, findings, confirmation status, corrective actions, and the date of the written decision. Despite this, the facility did not follow its own procedures, resulting in unresolved grievances and a lack of communication with the resident regarding the outcomes of her complaints.
Failure to Complete Annual Employee Misconduct and Nurse Aide Registry Screenings
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation by not completing the required annual Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) screenings for one licensed vocational nurse (LVN). According to the facility's policy, all employees must be screened annually for any history of abuse, neglect, exploitation, or misappropriation of resident property by accessing the appropriate registries. However, record review and interview with the HR Coordinator revealed that the last annual EMR and NAR screening for the LVN in question was completed over a year prior to the review, and the subsequent screening was not performed until after the oversight was discovered. This lapse in following established screening procedures meant that the facility did not ensure ongoing compliance with its own abuse prevention policies and state requirements. The failure to conduct timely annual registry checks could have resulted in the continued employment of an individual who may have been listed for abuse, neglect, or exploitation, thereby not upholding the residents' right to be free from such mistreatment as outlined in the facility's policy.
Failure to Notify Ombudsman of Facility-Initiated Discharge
Penalty
Summary
The facility failed to provide required notification to the Office of the State Long-Term Care Ombudsman regarding a facility-initiated discharge for a resident. Specifically, when the resident was given a written discharge notice due to non-payment for a private room, the facility did not send a copy of this notice to the local Ombudsman at the same time as it was provided to the resident. Although the discharge notice stated that a copy had been sent to the Ombudsman, interviews and record review confirmed that this was not done. The resident involved had a complex medical history, including generalized anxiety disorder, bipolar disorder, diabetes mellitus type 2, hypertension, congestive heart failure, and lupus. She was alert and oriented, with a BIMS score indicating cognitive intactness, and was admitted from home. The care plan noted her need for 24-hour licensed nursing care and a history of making false accusations, as well as a preference for a private room due to PTSD. The discharge was initiated after the resident was unable to pay for a private room and did not qualify for Medicaid. Interviews with the local Ombudsman and facility Administrator revealed discrepancies in the facility's documentation and communication. The Ombudsman was not aware of the discharge notice and had not received a copy, despite the facility's policy and the Administrator's initial claim that the notice had been sent. The Administrator later confirmed that the required notification to the Ombudsman had not been completed as per regulatory requirements.
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 and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Protect Resident from Abuse and Inadequate Reporting of Allegation
Penalty
Summary
The facility failed to ensure that a resident was protected from abuse, neglect, and exploitation after the resident reported an incident of sexual abuse by a certified nursing assistant (CNA). The resident, who had vascular dementia, hemiplegia, hemiparesis, and required maximal assistance with activities of daily living, alleged that the CNA inappropriately touched him during a shower. The resident initially did not report the incident due to embarrassment but later disclosed it to staff. Despite this disclosure, the alleged perpetrator was not suspended, and the allegation was not investigated or reported to local law enforcement or the State Agency as required by facility policy and regulations. Multiple staff members became aware of the allegation through direct disclosure by the resident or through communication among staff. However, there was a breakdown in the reporting process, as some staff assumed others had reported the incident, and key individuals, including the ADON and charge nurse, did not ensure the allegation was escalated to the Administrator or documented appropriately. The Administrator stated she was not notified of the allegation and denied any knowledge of the incident. There was no documentation of the allegation in the resident's progress notes, 24-hour reports, or self-reports to the state agency during the relevant period. The facility's own abuse and neglect policy required immediate suspension of the alleged perpetrator, prompt investigation, and timely reporting to authorities, none of which occurred following the resident's report. The only action taken was to restrict male staff from providing care to the resident, without further investigation or protective measures for other residents. This failure to follow established protocols resulted in an Immediate Jeopardy situation, as residents were not protected from potential further abuse or harm.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made. Specifically, a male resident with vascular dementia, hemiplegia, hemiparesis, and moderate cognitive impairment reported to staff that a certified nursing assistant (CNA) had sexually abused him during a shower. The resident initially delayed reporting the incident due to embarrassment, but later informed staff members, who did not immediately escalate the allegation to the facility administrator or law enforcement as required by policy and regulation. Multiple staff interviews revealed that the resident's report of sexual abuse was communicated among staff, including a medication aide, charge nurse, and assistant director of nursing (ADON), but there was confusion and lack of clarity regarding who was responsible for notifying the administrator and external authorities. The ADON stated that he informed the administrator by phone, but the administrator denied receiving any such report or having knowledge of the allegation. Documentation review showed no record of the abuse allegation in the resident's progress notes, 24-hour reports, or self-reports to the state survey agency during the relevant period. The CNA accused of abuse continued to work in the facility and was not suspended until months after the initial allegation. The facility's abuse/neglect policy required immediate reporting of all allegations to the administrator and appropriate authorities, but this protocol was not followed. Staff interviews indicated inconsistent understanding and execution of reporting procedures, with some staff assuming others had reported the incident. The lack of timely and proper reporting resulted in a failure to protect residents from potential further harm and did not meet regulatory requirements for abuse allegation management.
Removal Plan
- Abuse allegation investigations are ongoing. All new investigations start immediately upon receiving an allegation.
- The resident was interviewed at the time of discovery and a trauma informed care assessment was completed by the DON. Results were no negative outcomes.
- One on One in-service on Abuse Reporting with the Administrator, DON, by Area Director of Operation (ADO).
- One on One in-service on Investigating allegations with the Administrator, DON, by ADO.
- Staff working with alleged perpetrators have been interviewed by the Administrator, Director of Nursing, ADO, and Compliance Nurse.
- The alleged perpetrator was suspended, pending the outcome of the investigation.
- The ADON was suspended, pending the outcome of the investigation.
- Notification of Authorities: Law enforcement and HHSC were notified promptly in accordance with state-mandated reporting guidelines.
- Emotional Support: Social services and/or a mental health provider were contacted to provide counseling and emotional support to the resident; referral was sent.
- All residents who were able to be interviewed had safety surveys by the social worker. No abuse incidents were reported.
- All residents who were able to be interviewed were interviewed by DON/Compliance Nurse/Social worker. A new skin assessment was completed on all non-verbal residents by the same group with no abnormal findings.
- The following in-services were initiated by the Administrator/ADO: Any staff member not present or in-service will not be allowed to assume their duties until in-service.
- All Staff in-serviced on: Abuse/Neglect with special focus on sexual abuse; Abuse/Neglect Reporting; Who to Report Abuse/Neglect to Administrator and Director of Nursing. A second layer of reporting was added to prevent oversight of a single individual.
- All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report.
- The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services.
- New staff will be in service during orientation before assuming any duties.
- The medical director was notified of the immediate jeopardy situation.
- The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review.
- The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents to ensure resident safety/satisfaction with the outcome of the investigation.
- The Area Director will monitor abuse allegations reported by residents and or staff and check the real-time system, which monitors keywords like abuse documentation and PCC for any incidents and accidents.
- The QA committee will review the findings of abuse allegations and investigations monthly and make changes to the system as needed until substantial compliance is achieved.
Failure to Investigate and Respond to Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a male resident with vascular dementia, hemiplegia, and moderate cognitive impairment. The resident reported that a CNA had inappropriately touched him during a shower, but the incident was not immediately or properly reported, documented, or investigated according to facility policy. Multiple staff members became aware of the allegation at different times, but there was confusion and lack of clarity regarding who was responsible for reporting the incident to administration, resulting in delays and incomplete communication. Despite the resident expressing discomfort and specifically requesting that the alleged perpetrator not provide care, the CNA continued to work in the facility and had access to other residents. There was no evidence that the alleged perpetrator was removed from resident care or suspended pending investigation until much later. Documentation in the resident's progress notes, 24-hour reports, and other records did not reflect the allegation or any investigation, and the administrator denied knowledge of the incident until it was brought to her attention by surveyors. Interviews with staff revealed inconsistent understanding and execution of abuse reporting protocols. Some staff assumed others had reported the incident, while others failed to document or escalate the allegation as required. The facility's own abuse/neglect policy required immediate investigation and administrative review, but these steps were not followed. The lack of timely and comprehensive response to the allegation resulted in a failure to protect the resident and prevent potential further abuse or mistreatment.
Failure to Develop and Implement Person-Centered Care Plan Reflecting Resident Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with specific preferences and needs identified in their assessment. The resident, a male with vascular dementia, hypertension, hemiplegia, hemiparesis, and lack of coordination, was admitted with moderate cognitive impairment. A Social Services Quarterly Assessment documented that no male CNAs should be in the resident's room, following an allegation of sexual abuse involving a male CNA. However, this preference was not reflected in the resident's care plan, and there was no documentation to ensure the preference was communicated or implemented. Multiple staff interviews revealed inconsistent awareness and understanding of the resident's preference regarding male CNAs. Some staff recalled being told verbally not to allow male CNAs in the resident's room, while others were unaware of any such instruction or the reason behind it. The social worker, who completed the assessment, was no longer employed, and the current social worker was unaware of the preference or its origin. Nursing staff and administration acknowledged that the information should have been included in the care plan but was not, and there was no documentation of the incident or the instructions given to staff. The facility's policy requires that each resident have a person-centered comprehensive care plan developed and implemented to meet their preferences and needs. Despite this, the resident's care plan did not address the documented preference for no male CNAs, and there was a lack of communication and documentation among staff to ensure the resident's needs and preferences were met as identified in the assessment.
Failure to Document Allegation of Sexual Abuse in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, there was no documentation in the resident's progress notes or 24-hour reports regarding an allegation of sexual abuse made by the resident. The resident, who had vascular dementia, hypertension, hemiplegia, hemiparesis, and lack of coordination, reported being inappropriately touched by a CNA during a shower. Although the resident initially did not report the incident due to embarrassment, he later informed facility staff. Interviews with staff revealed that the allegation was communicated among staff members, but none of the involved staff documented the incident in the resident's medical record or facility reports. The facility's own documentation policy requires that all observations, investigations, and communications involving resident care and treatments be recorded accurately and completely in the clinical record. Despite this, neither the nursing staff nor the interdisciplinary team ensured that the allegation was documented. The administrator confirmed that there was no documentation of the event, statements, or incident reports related to the allegation, emphasizing the importance of such documentation for continuity of care.
Lack of Privacy for Resident Phone Calls
Penalty
Summary
The facility failed to ensure that residents had reasonable access to a telephone and a private place to make calls without being overheard. This deficiency was observed in the cases of three residents who were reviewed for telephone use. Resident #17, who was cognitively intact, was seen using a phone at the nurses' station, where other residents and staff were in close proximity, compromising his privacy. The phone in the chapel, which was supposed to offer privacy, was not operational due to ongoing construction, leaving residents without a private option. Interviews with staff and residents revealed that the lack of privacy was a common issue. LVN C acknowledged the need for privacy and mentioned that the chapel phone was not working. CNA A and the Social Worker also confirmed the privacy concerns, with the Social Worker admitting she was unsure if she had been trained on residents' rights to privacy. Residents expressed discomfort and embarrassment due to the lack of privacy, with some preferring to use the phone at the nurses' station despite the presence of others. The facility's policy on resident rights, which includes the right to private phone calls, was not adhered to. The Administrator and DON acknowledged the privacy violation, with the Administrator noting that the chapel phone was supposed to be functional but was not. The deficiency was further highlighted by the fact that some staff were unaware of the residents' need for privacy during phone calls, and the available cordless phones did not provide adequate coverage for private use in residents' rooms.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #39, who has diabetes and peripheral vascular disease, was not seen by a podiatrist, resulting in long, yellow, and chipped toenails. Despite having a care plan that included podiatry services, there was no physician's order for podiatrist services, and the resident had not been seen by a podiatrist in five months. The facility's staff, including CNAs and nurses, failed to document the need for toenail care, and there was a lack of communication and follow-up regarding the scheduling of podiatry appointments. Resident #33, who has severe cognitive impairment and dementia, exhibited wandering behavior that was not addressed in her care plan. The resident was observed entering other residents' rooms, mistakenly believing they were her own. Although staff were aware of her wandering behavior, there were no documented interventions in her care plan to address this issue. The MDS Coordinator and Social Worker acknowledged the oversight and the lack of a system for reporting resident behaviors to ensure they are included in care plans. The facility's policy and procedure manual on comprehensive care planning requires that each resident have a person-centered care plan that addresses their medical, physical, and psychosocial needs. However, the facility failed to adhere to this policy, resulting in inadequate care for Residents #39 and #33. The lack of proper documentation, communication, and follow-up contributed to the deficiencies observed during the survey.
Failure to Provide Adequate Foot Care for Residents
Penalty
Summary
The facility failed to provide proper foot care for two residents, leading to deficiencies in maintaining their foot health. Resident #39, a cognitively intact woman with diabetes and peripheral vascular disease, did not receive timely podiatry services. Despite having a care plan that required regular podiatrist visits and toenail maintenance, there was no record of a podiatrist appointment for her. Observations revealed her toenails were overgrown and discolored, and interviews with staff indicated a lack of communication and documentation regarding her need for podiatry care. Resident #62, who has severe cognitive impairment and requires assistance with personal care, also did not receive adequate foot care. Her care plan included regular toenail checks and trimming, but observations showed her toenails were long, thick, and discolored. The last podiatrist visit was several months prior, and there was no follow-up appointment scheduled. Staff interviews revealed that the responsibility for scheduling podiatrist appointments had recently changed hands, leading to lapses in care. The facility's policy required daily foot assessments and podiatrist referrals for residents with conditions like diabetes. However, there was a breakdown in the process, with CNAs failing to document and report long toenails, and nurses not scheduling necessary appointments. This lack of coordination and adherence to policy resulted in residents not receiving the foot care they needed, putting them at risk for complications.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, Resident #26 and Resident #39, by not maintaining clean oxygen concentrator filters. For Resident #26, who has a medical history of Chronic Obstructive Pulmonary Disease (COPD) and moderate cognitive impairment, the oxygen concentrator filter was observed to be dirty with debris. Interviews with staff revealed that the responsibility for cleaning the filters was assigned to CNAs and nurses on the night shift every Friday. However, the order for weekly cleaning had been discontinued by a nurse who was no longer employed, and no documentation was provided to justify this change. Resident #39, who has diagnoses including hypoxia, asthma, and COPD, was also found to have a thick coat of dust on the oxygen concentrator filter. The care plan for Resident #39 did not address the cleaning of the oxygen concentrator filter, and the order for weekly cleaning had been discontinued. Interviews with staff indicated that the cleaning should occur weekly, but the responsibility was not clearly enforced, leading to the observed deficiency. The facility's policy and the manufacturer's manual both require that oxygen concentrator filters be cleaned weekly with soap and water and allowed to air dry completely. The failure to adhere to these guidelines and maintain clean filters could impair the performance of the oxygen concentrators and pose risks to the residents' health. The Director of Nursing confirmed the discontinuation of the cleaning orders but was unaware of the reasons behind it.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in several deficiencies related to medication management. Observations and interviews revealed that the facility did not have a reliable system for the accurate reconciliation of controlled substances. Specifically, the Controlled Substance Medication Count Record for certain rooms showed blanks in documentation, indicating that the on-coming and off-going nurses did not verify and sign off on the controlled substances count as required. This lapse was confirmed by an LVN who admitted to signing the record before actually counting the substances, which could lead to drug diversion. Additionally, the facility did not maintain proper storage conditions for medications. Observations showed that liquid medications in the medication carts had dried drippings on the sides of the bottles, and some bottles were not dated when opened, contrary to the manufacturer's instructions. Medications were not stored separately according to their routes of administration, and the sharps disposal container was overfilled, posing a safety risk. These issues were noted in the medication carts on two different halls, indicating a broader problem with medication storage practices. Furthermore, the facility failed to update medication labels following changes in physician orders. An instance was observed where a pharmacy label for a resident's medication did not reflect a change in dosage and administration frequency, as per the new physician's order. This oversight was only corrected after being pointed out by a state surveyor, highlighting a risk of administering incorrect medication dosages. Interviews with facility staff revealed that while training on these procedures was provided, the implementation was inconsistent, leading to these deficiencies.
Failure to Refrigerate Opened Probiotic Supplement
Penalty
Summary
The facility failed to ensure proper pharmaceutical services by not refrigerating an opened bottle of Acidophilus Probiotic Dietary Supplement as required by the manufacturer's label. During an observation on the 4th floor, a Medication Aide's cart was found to contain the probiotic supplement, which had been opened on 11/03/24 and was not refrigerated. LVN B confirmed the oversight and immediately removed the bottle from the cart. This failure could potentially affect the availability and efficacy of medications for residents by not adhering to the manufacturer's storage specifications.
Deficiencies in Food Storage and Sanitation Procedures
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Foods in the refrigerator were not stored in sealed containers, and one of the spice bottles on a metal storage rack was not completely sealed. Additionally, the kitchen ceiling tiles were not maintained properly, with dried brown water stains present, and ceiling vents above the food preparation area were covered in lint. Missing ceiling tiles were noted in the room between the kitchen and the dishwashing room, as well as in the dry storage room. The vegetable sink was not operational, and the trash can next to the handwashing sink was broken, with a cracked lid and a non-functional foot pedal. The facility also failed to follow the Three-Compartment Sink Procedures for sanitizing pots and pans. During an observation, a dietary staff member was seen washing and rinsing a pan and then quickly dipping it in and out of the sanitizer compartment, contrary to the posted instructions that required immersion for at least one minute. The dietary manager confirmed that staff had been trained to follow these procedures, but the staff member admitted to not following them due to nervousness. The registered dietitian confirmed that the sanitizing solution used required a one-minute immersion. The facility's dietary services policy and procedure manual, dated 2012, outlined the requirements for food storage and equipment sanitation, which were not followed. The manual specified that all open packages of food should be stored in closed containers or sealed bags and dated. It also detailed the proper sanitizing methods for equipment and utensils, which were not adhered to during the survey. These deficiencies in food storage, kitchen maintenance, and sanitation procedures could potentially lead to foodborne illnesses among residents.
Infection Control Deficiencies in Hand Hygiene and Storage Practices
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by several observations and interviews. During a meal service, an LVN was observed distributing meal trays without performing hand hygiene after repositioning a resident, which contradicts the facility's policy requiring hand hygiene between resident interactions. Interviews with staff, including the DON and other nurses, confirmed that hand hygiene is a critical component of infection control training, yet there was inconsistency in its application. The facility's Infection Control Policy mandates hand washing after each direct resident contact, but this was not adhered to during the observed meal service. Additionally, the facility did not ensure proper storage of medical supplies and personal belongings, which could lead to cross-contamination. An open package of gauze non-sterile sponges was found on a treatment cart, and personal belongings were improperly stored on a clean linen table shelf. The housekeeping supervisor and staff confirmed that clean linen should be stored in covered carts and personal items should not be stored in areas designated for clean linen. These lapses in protocol could contribute to the spread of infections within the facility.
Deficiency in Maintaining Safe and Functional Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations during initial rounds revealed that several resident rooms had closet doors that were either missing or off their tracks, lacking the necessary Sliding Closet Door Bottom Guide. This guide is essential to prevent the doors from swinging or derailing, which could lead to potential injuries. Interviews with the Social Worker and the Administrator highlighted a lack of communication and awareness regarding the issue, as the Social Worker had not reported the loose doors to the relevant authorities, and the Administrator acknowledged the potential hazard posed by the malfunctioning doors. Further observations with the Maintenance Supervisor confirmed that the closet doors were indeed off the tracks and lacked the necessary guides, posing a risk of falling and causing injury. The Maintenance Director demonstrated that some doors were jammed due to obstructions inside the closets, exacerbated by the absence of the bottom guide. The facility's Social Service Manual emphasizes the residents' right to a safe and comfortable environment, yet the current state of the closet doors contradicts this policy, indicating a deficiency in maintaining essential equipment in safe operating condition.
Failure to Ensure Call Light Accessibility for Resident with Physical Limitations
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for their needs and preferences. The resident, who has severe cognitive impairment and physical limitations due to Parkinson's disease, cerebellar ataxia, seizures, and traumatic brain injury, was observed lying in bed with the call bell clipped on the overhead light, out of reach. The resident's care plan specifically included an intervention to keep the call light within reach due to their risk for injury related to a seizure disorder. Interviews with facility staff revealed a lack of communication and adherence to the care plan. A CNA acknowledged that the resident could not use the call light due to bilateral hand contractures and stated that the resident was checked every 15 minutes or would yell for assistance. However, the ADON and LVN indicated that a pad call light should have been provided, as the resident could use it with their left hand. The facility did not have a call light policy, and the staff had not reported the resident's inability to use a regular call light, resulting in the deficiency.
Failure to Respect Resident's Privacy and Dignity
Penalty
Summary
The facility failed to ensure that residents had the right to be treated with respect and dignity, specifically for one resident who experienced an incident where a nurse entered his room without permission after knocking. This incident occurred when the resident was naked, leading to feelings of embarrassment and a loss of dignity. The resident had a history of making false accusations and negative statements about staff, but his cognitive abilities were intact, and he was independent in his activities of daily living. The resident reported the incident to the Social Worker and the Ombudsman, stating that a nurse entered his room without his approval while he was naked. The nurse later refused to give her name when asked by the resident. The facility's Social Worker and Administrator acknowledged the resident's grievance and recommended that staff knock and wait for permission before entering a resident's room. However, the Social Worker also mentioned that staff have the right to enter a room if there is no response to ensure the resident's safety. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity. Despite this policy, the incident with the resident was not adequately addressed, as the nurse involved did not respond to follow-up calls, and the grievance remained unresolved. The Administrator confirmed that staff should knock and wait for permission to enter but may need to enter without permission in case of an emergency, especially for residents with a history of falls.
Violation of Resident's Right to Receive Unopened Mail
Penalty
Summary
The facility failed to ensure that residents received unopened mail, violating their right to privacy. Specifically, Resident #8 received a letter from a family member that was opened before it was delivered to him. The resident, who is cognitively intact with a BIMS score of 15, reported the issue to the Ombudsman and the facility's staff. The Business Office Manager (BOM) and BOM Assistant admitted to opening mail for residents unless they were on a specific list, which included Resident #8. Despite this, the BOM Assistant mistakenly opened Resident #8's mail, leading to the grievance filed by the resident. Interviews with various staff members, including the Social Worker, Activities Director, and Administrator, confirmed that the facility had a policy to deliver unopened mail to residents unless the facility was the representative payee. However, the BOM and BOM Assistant's actions contradicted this policy, as they routinely opened mail to determine its recipient. The facility's in-service training record and a list provided by the BOM highlighted residents who should receive unopened mail, but this protocol was not consistently followed. Resident #8's grievance was documented, and the Social Worker attempted to address the issue by ensuring the Activities Director would personally deliver the resident's mail. Despite this resolution, the initial failure to deliver unopened mail to Resident #8 represents a clear violation of resident rights. Interviews with other residents revealed that they did not receive their mail at the facility, further indicating systemic issues with mail handling and delivery.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse when an altercation occurred between two residents. On the morning of the incident, Resident #2 verbally threatened Resident #1, but this was not reported or investigated by the staff. Later that day, Resident #2 physically assaulted Resident #1 in the dining room, resulting in a physical altercation. The staff present did not intervene in time to prevent the assault, and the incident was not properly reported or investigated by the facility's administration. Resident #1, who has severe cognitive impairment and a history of aggressive behavior, was not adequately protected from Resident #2. Despite Resident #1's known history of wandering and anxiety, the facility did not take sufficient measures to monitor and redirect him. Resident #2, who has a history of adverse behavior and is diagnosed with schizoaffective disorder and dementia, was also not adequately monitored or redirected, leading to the physical altercation. The facility's failure to investigate the initial verbal threat and to protect Resident #1 from Resident #2 resulted in a physical altercation that could have been prevented. The facility's policies on abuse prevention and reporting were not followed, putting residents at risk of harm. The administrator, who is the Abuse Coordinator, was not informed of the initial verbal threat, and the incident was not investigated to determine the root cause and implement a plan to maintain safety for all parties involved.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement written policies that prohibit and prevent abuse, neglect, and exploitation of residents, specifically for two residents involved in altercations. On 02/26/2024, Resident #1 and Resident #2 were involved in a physical altercation where Resident #2 struck Resident #1 on the left cheek. This incident was not properly investigated, and the facility did not take necessary measures to protect Resident #1 from further harm. Additionally, an earlier verbal threat made by Resident #2 towards Resident #1 on the same day was not reported or investigated, which could have prevented the subsequent physical altercation. Resident #1, who has severe cognitive impairment and a history of aggressive behavior, was not adequately monitored or protected. His care plan included interventions for anxiety and aggressive behavior, but these were not effectively implemented. Resident #1 had been wandering and displaying signs of agitation in the days leading up to the incident, yet staff failed to intervene appropriately to prevent the altercation. Resident #2, who has a history of schizoaffective disorder and other behavioral disturbances, also had a care plan that included monitoring for aggressive behavior. Despite this, the facility did not take adequate steps to separate the residents or address the verbal threat made by Resident #2 earlier in the day. The lack of timely intervention and failure to report the initial verbal threat contributed to the physical altercation that occurred later in the day.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately or within 24 hours to the administrator and other officials. This deficiency was observed in the case of two residents who were involved in an altercation. LVN C did not report the incident where Resident #2 made contact with Resident #1's left cheek after becoming agitated. This incident occurred in the morning, but it was not reported to the Administrator, putting residents at risk of physical altercations that could result in injury. Resident #1, who has severe cognitive impairment and a history of aggressive behavior, was involved in the altercation with Resident #2. Resident #1's care plan included interventions to monitor and report any mental status changes, place him in a quiet area when anxiety occurs, and redirect him during episodes of adverse behavior. Despite these measures, the altercation occurred, and the incident was not reported as required. Resident #2, who has diagnoses including Parkinson's disease, depression, anxiety, and schizoaffective disorder, was also involved in the altercation. His care plan included monitoring for adverse behavior and removing him from unwanted stimuli. However, the incident where he verbally threatened and physically assaulted Resident #1 was not reported to the Administrator. The failure to report this incident and investigate it properly highlights a significant lapse in the facility's abuse prevention and reporting protocols.
Failure to Address Wandering Behaviors in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to maintain his highest practicable well-being. The resident, who had a history of aggressive behavior and severe cognitive impairment, exhibited ongoing wandering behaviors that were not adequately tracked or addressed. Despite being identified as at risk for wandering, the resident's care plan lacked specific interventions to manage these behaviors effectively. The facility's failure to monitor and document the resident's wandering behaviors placed him at risk of harm, including verbal and physical abuse from other residents. The resident's medical records revealed multiple instances of wandering and anxiety, with attempts at redirection often being unsuccessful. Progress notes documented the resident's wandering behaviors, including entering other residents' rooms and becoming verbally aggressive. However, there were no consistent orders for tracking these behaviors in the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) until March 2024, and even then, the monitoring was inconsistent. Interviews with facility staff, including the Director of Nursing (DON), indicated a lack of awareness and proper assessment of the resident's wandering behaviors. The DON acknowledged the importance of accurate care plans but stated that the resident's wandering was not considered problematic unless it involved exit-seeking behavior. The facility's dementia policy emphasized the need for a systematic approach to care, including the development of a care plan with specific interventions, which was not adequately followed in this case.
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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