Gulf Shores Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Falfurrias, Texas.
- Location
- 1301 S Terrell St, Falfurrias, Texas 78355
- CMS Provider Number
- 675630
- Inspections on file
- 27
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Gulf Shores Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep several hazard-prone areas secured, including an open chemical storage room with cleaning agents on one hall, an unlocked shower room containing hair and body cleaning products on another hall, and an unlocked supply closet housing an unprotected electrical fuse box. Staff interviews revealed that a housekeeper and CNAs had left these doors open or unlocked after retrieving supplies or transporting a resident, despite acknowledging that residents with dementia or Alzheimer's could enter these areas, slip and fall, lock themselves in, ingest chemicals, or access the fuse box.
A resident with dementia, ESRD on dialysis, impaired vision, and a severely impaired BIMS score had a designated responsible party, but the facility’s BOM bypassed this representative and obtained the resident’s signature on a retirement income address‑change form so the facility could receive pension checks directly. The BOM did not verify the resident’s cognitive status or consult the MDS nurse, despite acknowledging that low BIMS scores indicate inability to make informed decisions and that policy requires the representative’s signature. The resident’s representative, who worked part‑time at the facility, reported she was not contacted, questioned the authenticity of the printed signature, and stated the resident could not make such financial decisions. A CNA reported she did not witness the resident sign the form and described the resident’s cognition as poor, while the Administrator maintained that the resident could make his own decisions regardless of the low BIMS score, resulting in the facility failing to honor the representative’s authority.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a lack of established measures to prevent and control infections among residents and staff.
The facility did not post daily nurse staffing data for 43 days, as required by policy. The DON admitted the HR person responsible for this task was absent, and he was too busy to maintain the postings. This lapse could prevent access to important staffing information.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing medical needs. A resident's care plan lacked Enhanced Barrier Precautions for a dialysis catheter, another resident's plan did not address frequent removal of oxygen, and a third resident's arterial wound was not included in their care plan. These oversights were acknowledged by staff but not corrected in the care plans.
A resident with type 2 diabetes and moderate cognitive impairment did not receive her prescribed Tresiba FlexTouch Solution Pen Injector on 8 out of 9 occasions in November. RN A held the medication without notifying the physician or documenting it, despite no hold parameters. The DON was unaware of the pattern and acknowledged the importance of following physician orders. The facility's policy requires medications to be administered as prescribed and any concerns to be discussed with the prescriber.
A resident with diabetes did not receive their prescribed insulin, Tresiba, on 8 out of 9 occasions, and the facility failed to notify the physician. The resident's medical records showed a pattern of missed doses without a physician's order to hold the medication. Interviews with staff revealed a lack of communication and documentation, and the DON was unaware of the issue, leading to a deficiency identified by surveyors.
A facility failed to update a resident's care plan to reflect the removal of a urinary catheter, despite the change being noted in the quarterly MDS. The resident, with severe cognitive impairment and multiple diagnoses, had the catheter removed, but the care plan still indicated its presence. Staff interviews revealed that the MDS Coordinator missed updating the care plan, and the DON acknowledged the oversight.
A facility failed to ensure a resident's medi-port was accessed and flushed according to policy and physician's orders. The resident, with multiple health conditions, had inconsistencies in the documentation of medi-port procedures. Despite the resident expressing concerns about dehydration and urinary health, these were not documented or addressed by staff. The DON admitted that nurses lacked proper training for medi-port maintenance, contributing to the deficiency.
A facility failed to ensure proper placement of fall mats for a resident with a history of falls, as only one side of the bed had a mat despite the care plan requiring mats on both sides. Staff interviews confirmed the oversight, acknowledging the importance of mats in preventing injuries. The facility's Fall Prevention Program policy was not adequately followed, potentially risking resident safety.
A facility failed to ensure nursing staff were trained in managing an implanted medi-port for a resident, leading to missed flushes and improper documentation. The resident, with multiple health conditions, had inconsistencies in her Medication Administration Records, and staff interviews revealed a lack of training and confusion about orders. The Director of Nursing acknowledged the lapse in resuming orders for the saline flush, contributing to the deficiency.
Unsecured Chemical, Shower, and Supply Rooms Create Accident Hazards
Penalty
Summary
The facility failed to ensure that multiple areas were secured to keep the resident environment as free of accident hazards as possible. During an initial observation of the 400 wing, surveyors found the chemical storage room door wide open, with kitchen cleaning agents and other cleaning supplies accessible and no staff present in the hallway to monitor the area. On the 500 wing, the shower room was observed left unlocked after use, with hair and body cleaning agents inside. A CNA assigned to the 500 hall reported that she had taken a resident back to their room after a shower and left the shower room door open while transporting the resident. She acknowledged that leaving the door open posed a danger to residents with dementia or Alzheimer's, who could enter, slip and fall, lock themselves in, or ingest cleaning solutions like shampoo. On the 200 wing, the supply closet door was observed unlocked, and the closet contained an electrical fuse box that itself had no lock. A CNA and the ADON stated that only they had keys to this supply room and that it was their responsibility to ensure the door remained closed and locked. The CNA stated she must have left the door unlocked after retrieving supplies and recognized that a cognitively impaired resident could enter, lock themselves in, and open the fuse box, leading to electrocution. Another CNA assigned to the 200 hall stated she did not know the supply room had been left unlocked but understood that it was normally kept locked and that it was dangerous for residents to enter due to the fuse box. Staff interviews across these incidents consistently acknowledged that unsecured chemical rooms, shower rooms, and supply rooms with an electrical fuse box posed dangers to residents, particularly those with Alzheimer's or dementia.
Failure to Honor Resident Representative’s Authority in Financial Decision‑Making
Penalty
Summary
The deficiency involves the facility’s failure to recognize and honor the authority of a resident’s representative in financial decision‑making, despite the resident’s severe cognitive impairment. The resident was a 97‑year‑old male with dementia, end‑stage renal disease requiring dialysis, restlessness and agitation, hypertension, impaired vision, and a BIMS score of 3 indicating severe cognitive impairment. His care plan identified impaired cognitive function/dementia and directed staff to monitor and report changes in decision‑making ability and mental status. The face sheet listed a family member as the responsible party. During observation, the resident appeared flustered, had difficulty hearing, and was unable to understand and respond to surveyor questions, making interview attempts unsuccessful. The Business Office Manager (BOM) learned from the state that the resident had additional retirement income, which increased his monthly liability for room and board and resulted in an outstanding balance. The BOM reported that the responsible party had been keeping the extra retirement check and had entered into a promissory note to pay the balance. Instead of obtaining the responsible party’s signature, the BOM approached the resident directly in the hallway with a retirement income address‑change form so the facility could receive the retirement checks. The BOM stated she assumed the resident could make his needs known and did not verify the resident’s BIMS score or consult the MDS nurse, despite acknowledging that a low BIMS score would indicate the resident was not cognitively able to make an informed decision and that policy and procedure required obtaining the responsible party’s or appointed family member’s signature. The resident’s representative reported she did not understand why the BOM did not contact her at the facility where she worked part‑time and stated she believed the resident could not make such financial decisions due to his BIMS of 3. She also questioned the authenticity of the resident’s signature on the address‑change form, noting that the signature was printed while the resident normally signed in cursive. The BOM claimed a CNA had witnessed the signature, but the CNA stated she never saw the resident sign the form and only saw the BOM later waving the paper and saying she had obtained a signature. The CNA also described the resident’s cognitive status as poor, with difficulty remembering recent events and uncertainty about whether he could understand what he was signing. The Administrator stated that the resident could make decisions for himself regardless of the low BIMS score and that the state would have to deem a resident incompetent by court for the facility to take over financial responsibility, reinforcing that the facility treated the resident’s signature as valid rather than deferring to the designated representative.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post daily nurse staffing data at the beginning of each shift in a prominent place accessible to residents and visitors. This deficiency was observed for 43 consecutive days, from early February to late March. During an observation on March 22, the surveyor noted that the nurse staffing data displayed was outdated, showing a date from early February. The Director of Nursing (DON) acknowledged the lapse, explaining that the Human Resources (HR) person responsible for completing and posting the form had not been working for about a month. In the HR person's absence, the DON was responsible for this task but admitted to being too busy to maintain the postings. The facility's policy requires that within two hours of each shift's start, the number of licensed and unlicensed nursing personnel responsible for direct resident care be posted in a clear and readable format. This information should include the facility name, date, resident census, shift schedule, and the type and category of nursing staff working each shift. The failure to adhere to this policy could prevent residents, families, and visitors from accessing important information about the staffing levels responsible for resident care.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which did not include measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #14's care plan did not reflect the need for Enhanced Barrier Precautions for his right chest wall dialysis catheter, despite having severe cognitive impairment and being dependent on renal dialysis. The care plan lacked specific interventions for managing the Perma catheter, which is crucial for preventing infections and complications. Resident #24, who is cognitively intact, frequently removed her oxygen cannula and tubing, yet her care plan did not address this behavior. Despite physician orders for continuous oxygen therapy, observations and interviews revealed that she often did not wear her oxygen, and staff were aware of this issue. The Director of Nursing acknowledged that the care plan should have included this behavior to ensure proper management and intervention. Resident #37 had an arterial wound on his right heel, which was not included in his care plan. Despite having a moderate cognitive impairment and being at risk for pressure ulcers, the care plan did not reflect the wound care orders. Interviews with the MDS Coordinator and DON revealed that the wound was overlooked in the care planning process, although the resident was receiving wound care and weekly skin assessments. The facility's policies emphasize the importance of updating care plans as residents' conditions change, but this was not adhered to in these cases.
Failure to Administer Tresiba as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Tresiba FlexTouch Solution Pen Injector. The resident, a female with type 2 diabetes mellitus and moderate cognitive impairment, was supposed to receive 62 units of Tresiba subcutaneously once a day. However, RN A did not administer the medication on 8 out of 9 opportunities in November 2024, despite there being no hold parameters for the medication. The resident's blood sugar levels were recorded on the days the medication was held, but the physician was not notified of the medication being withheld, nor was it documented in the progress notes. The Director of Nursing (DON) was unaware of the pattern of missed doses and stated that the facility's process involved pulling an orders report daily, but it did not indicate when medications were not given. The DON acknowledged the importance of following physician orders to prevent undesired consequences and stated that any held medication should be communicated to the physician immediately. The facility's Medication Administration Policy requires medications to be administered as prescribed and any concerns about dosages to be discussed with the prescriber. The physician was also unaware of the medication being held and expressed that he would have expected to be notified to provide clarification and ensure effective care for the resident.
Failure to Notify Physician of Held Medication
Penalty
Summary
The facility failed to immediately inform a resident, consult with the resident's physician, and notify the resident's representative when there was a significant change in the resident's status. Specifically, the facility did not notify the physician when a resident's prescribed medication, Tresiba, was not administered on 8 out of 9 occasions. This failure was identified during a review of the resident's medical records and interviews with facility staff. The resident involved was a female with a history of type 2 diabetes mellitus with hyperglycemia and diabetic polyneuropathy, as well as a cognitive communication deficit. The resident's medication administration record indicated that the prescribed insulin, Tresiba, was held by a registered nurse on multiple occasions without a physician's order to do so. The facility's Director of Nursing (DON) and other staff members were unaware of the pattern of missed doses and did not notify the physician, which could have led to complications in the resident's health. Interviews with facility staff revealed that there was a lack of communication and documentation regarding the held medication. The DON and other staff members acknowledged the importance of following physician orders and notifying the physician when medications are held. However, the facility's procedures for monitoring medication administration and notifying physicians were not effectively implemented, leading to the deficiency identified by the surveyors.
Failure to Update Care Plan for Resident Without Urinary Catheter
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was periodically reviewed and revised by a team of qualified persons after each assessment. Specifically, the care plan for a resident who no longer had a urinary catheter was not updated to reflect this change. The resident, a male with severe cognitive impairment and multiple diagnoses including end-stage renal failure and dementia, had his urinary catheter removed on a specific date, but this change was not documented in his care plan. Despite the removal of the catheter being noted in the resident's quarterly MDS, the care plan still indicated the presence of a Foley catheter. Interviews with facility staff revealed that the MDS Coordinator was responsible for updating care plans as conditions and needs changed, but missed the removal of the urinary catheter for this resident. The Director of Nursing (DON) acknowledged that the catheter should have been removed from the care plan when the orders were discontinued, attributing the oversight to a lapse in their process. The facility's policy requires that care plans be revised when there is a significant change in a resident's condition and at least quarterly, but this was not adhered to in this instance.
Failure to Properly Access and Flush Resident's Medi-Port
Penalty
Summary
The facility failed to ensure that a resident's implanted medi-port was accessed and flushed according to policy and physician's orders. The resident, a cognitively intact female with multiple diagnoses including epilepsy, heart failure, and dysphagia, had a medi-port that was not consistently accessed or flushed as required. The Medication Administration Records (MAR) showed discrepancies in the documentation of the medi-port access and flushes, with several instances where the procedures were either not signed off or not performed as scheduled. Interviews with the resident revealed that she felt dehydrated and had concerns about her urinary health, which she communicated to the nursing staff. However, the staff interviews indicated that these concerns were not documented or addressed. The resident also mentioned that she was told the facility would not pay for the necessary kits to flush her port if she did not allow the procedure to be done correctly. Additionally, the resident's care plan indicated the presence of an implanted port, but there was no clear documentation of the orders to resume or discontinue the flushes after they were put on hold. The facility's Director of Nursing (DON) acknowledged that the nurses were not properly trained or in-serviced on accessing and maintaining the medi-port. The facility's policies required staff to have training and demonstrated competency in intravenous therapy, but this was not adhered to. The lack of proper documentation and training, along with the failure to follow physician orders, contributed to the deficiency in providing appropriate treatment and care for the resident.
Failure to Ensure Proper Placement of Fall Mats
Penalty
Summary
The facility failed to ensure that the environment for a resident was free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents. Specifically, the facility did not ensure that floor mats were in place on both sides of the bed for a resident who had a history of falls. Observations revealed that the resident had a floor mat on the left side of the bed but not on the right side, despite the care plan indicating the need for fall mats as an intervention following multiple unwitnessed falls. Interviews with staff, including a CNA, an LVN, and the DON, confirmed that the floor mats were intended to prevent injuries in case of a fall and should have been placed on both sides of the bed. The staff acknowledged their responsibility to ensure the mats were correctly positioned but admitted they had not noticed the missing mat. The facility's Fall Prevention Program policy required assessments and specific interventions to minimize falls, but the lack of proper mat placement indicated a failure to adhere to these guidelines, potentially placing the resident at risk for injury.
Inadequate Training and Management of Implanted Medi-Port
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and competent in managing and maintaining an implanted medi-port for a resident, leading to potential risks for the resident's health. The resident, a cognitively intact female with multiple diagnoses including epilepsy, heart failure, and dysphagia, had an implanted medi-port that required regular flushing. However, the facility did not provide the necessary education to the nursing staff on the protocols for accessing and flushing the medi-port, resulting in missed flushes and improper documentation. The resident's Medication Administration Records (MAR) and Treatment Administration Records (TAR) showed inconsistencies and omissions in the scheduled flushes of the medi-port. For instance, the MAR for November 2024 indicated that a scheduled saline flush was not signed as performed, and similar issues were noted in previous months. Additionally, there was confusion among the nursing staff regarding the orders for flushing the medi-port, with some staff members incorrectly believing that the port was being flushed with heparin, despite no such order existing. Interviews with the nursing staff and the Director of Nursing (DON) revealed a lack of training and annual skills checkoffs for managing implanted medi-ports. The DON acknowledged that the order for the saline flush was put on hold and never resumed, leading to further confusion and improper care. The facility's policies on intravenous catheter management and documentation were not adhered to, contributing to the deficiency in care for the resident.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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