Harker Heights Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Harker Heights, Texas.
- Location
- 415 Indian Oaks Dr, Harker Heights, Texas 76548
- CMS Provider Number
- 675909
- Inspections on file
- 57
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Harker Heights Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to follow care-planned interventions for multiple residents requiring assistance with incontinence care and personal hygiene. Several residents with bowel and bladder incontinence, self-care deficits, and cognitive impairment reported long delays in call light response, sometimes up to an hour or more, and described being left wet or soiled for extended periods, including overnight. One resident with severe cognitive impairment was observed crying for help while a call light went unanswered for over 14 minutes until a surveyor alerted staff. Another resident with paraplegia and a history of sacral MASD reported waiting 7–8 hours at night to be changed, and observation showed pink, dry skin breakdown on her sacrum and thighs. Staff interviews confirmed that call lights were expected to be answered promptly and that rounds should occur every two hours, yet they acknowledged that with current assignments, call lights were not always answered in a timely manner and residents were not consistently checked and changed as required by their care plans.
Surveyors found a medication cart assigned to one hall left unattended, unlocked, and accessible in a main lobby area, with the locking mechanism protruding and drawers easily opened. An RN acknowledged responsibility as charge nurse for ensuring carts remained locked, and an LVN assigned to the cart confirmed that policy required carts to be locked at all times because someone could access them and residents were at risk of taking medications not prescribed to them. The DON and administrator both stated that all nurses were expected to know and follow the policy that medication carts must remain locked when not in use, and facility policy documents confirmed that medication carts and their contents must be kept closed, secured, and/or in line of sight when not in use.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room due to a non-functioning bathroom, but neither the resident nor her responsible party received written notice of the change. Facility staff confirmed that room changes were communicated verbally and not in writing, and the facility's policy did not require written notification. This resulted in a failure to honor the resident's right to receive written notice before a room or roommate change.
A facility failed to enforce its smoking policy when a CNA was observed using a vape device while providing care to a cognitively impaired resident with multiple medical conditions. The incident occurred in a non-designated area, contrary to facility policy, and was confirmed through video evidence and staff interviews.
A deficiency was cited for not ensuring a resident's right to a safe, clean, comfortable, and homelike environment, including the safe provision of treatment and daily living supports.
Surveyors found that multiple food items in the kitchen refrigerator, including salad greens, pasta noodles, and a yellow liquid with chunks, were not labeled with opened or discard by dates. Both the DM and interim ADM confirmed that staff were responsible for labeling and that failure to do so could result in serving spoiled food.
A facility failed to provide appropriate pain management for a resident with severe cognitive impairment by using an incorrect numerical pain scale instead of a pain ad assessment. The resident, who had a history of falls and was unable to verbalize pain, was repeatedly assessed with a pain level of 0/10, despite his condition. Staff interviews revealed inconsistent training and understanding of proper pain assessment tools, and the facility lacked a policy on assessment accuracy.
A resident with a history of tremors was not provided a modified cup with a lid, leading to a coffee spill. The NAIT, unfamiliar with the resident's needs, served coffee in a standard mug, resulting in the spill. The resident's care plan required a modified cup due to her condition, but the NAIT did not know how to access the Kardex to verify this requirement.
The facility failed to maintain accurate records and periodic reconciliation of controlled drugs, with missing documentation on Narcotic Count Sheets for several shifts across different halls. Despite training and expectations for nurses to count narcotics together and sign the sheets, compliance was not ensured, leading to potential risks of drug diversion.
The facility failed to provide palatable and properly prepared meals, with residents receiving lukewarm, unseasoned food. The dietary staff lacked proper measuring equipment, leading to inconsistencies in puree diet preparation. Residents expressed dissatisfaction, with some resorting to alternative food options.
The facility failed to maintain residents' dignity during meal times, affecting four residents. A CNA fed three residents simultaneously, contrary to training, while another resident waited 45 minutes for her meal, causing distress. Staff interviews revealed a lack of adherence to expected care standards, and no policy on meal service was provided.
The facility failed to maintain proper kitchen sanitation practices. A dietary staff member did not wash or sanitize her hands while preparing pureed meals, potentially contaminating the food. Another staff member did not wear a beard guard correctly, leaving his facial hair exposed over a food prep table. The facility's sanitation policy requires hand hygiene and hair restraints, but training records were not provided.
The facility failed to provide adequate assistance and care for two residents. A resident with a history of cerebral infarction and other conditions was left without assistance by an ADON, despite needing help with bed mobility. Surveillance footage showed the resident struggling and calling for help, with a delayed response from staff. Another resident was fed by an unqualified Activity Assistant, posing a risk of aspiration. The DON and Administrator acknowledged the need for qualified staff to assist residents.
Two residents with severe cognitive impairment did not receive proper nail care, resulting in poor hygiene and potential health risks. Observations showed blackish/brownish substances under their nails and uneven edges, despite care plans requiring regular maintenance. CNAs were responsible for nail care, except for diabetic residents, but staff were unaware of any refusals and did not recall training dates.
Two residents in a facility were served meals that did not accommodate their dietary needs. One resident, with cognitive impairments, was served beef despite disliking it, while another resident with a gluten allergy was served gluten-containing foods. Staff interviews revealed a lack of awareness and adherence to dietary restrictions, and the facility lacked gluten-free products.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter. Two CNAs provided care without wearing gowns, despite EBP requirements. A CNA was unaware of the resident's EBP status due to missing information in the Kardex. The DON confirmed that staff should use the Kardex to verify precautionary measures.
A resident with severe cognitive impairment was sent to the hospital for low blood pressure during dialysis, but the facility failed to notify the responsible party (RP) as required. Interviews revealed that the LVN assumed the dialysis center would inform the RP, leading to a lapse in communication. The facility's policy mandates notifying the RP of changes in condition, which was not followed in this case.
A resident was admitted to a facility with hospital discharge orders for insulin due to type II diabetes, but the order was not instated. Instead, the resident was given anti-seizure medications without a seizure diagnosis, leading to a sudden change in consciousness and hospitalization. The facility failed to ensure accurate medication reconciliation and verification of orders, resulting in an Immediate Jeopardy situation.
A resident admitted with a hip fracture and existing skin issues did not receive timely wound care, leading to a stage III pressure ulcer. The facility failed to implement standing treatment orders upon admission, and the WCN was not notified promptly. This delay in care highlighted a systemic issue in the facility's wound management practices.
The facility failed to have certified Activities Directors (ADs) for its activities program, as required by their policy. The newly hired AD, previously a CNA, was not yet certified, and neither the AD for the secured memory care unit nor the AD for the rest of the residents were certified. This lack of certification resulted in fewer activity opportunities for residents, potentially affecting their quality of life.
A resident with severe cognitive impairment sustained a black eye of unknown origin, and the facility failed to notify the resident's representative in a timely manner. The injury was observed by staff, but the representative was not informed until several hours later, and there was a lack of clarity among staff regarding notification procedures.
A resident with severe cognitive impairment and dependency on staff for ADLs had an unclean wheelchair with brown spots and a foul odor. Interviews revealed confusion among staff about who was responsible for cleaning wheelchairs, with no consistent oversight or schedule in place. The facility's policies were not effectively implemented, leading to the resident's wheelchair remaining unclean, impacting their dignity and potentially their health.
A resident with severe cognitive impairment was found with a black eye, and the LTC facility failed to report the incident to the State Agency within the required 24-hour timeframe. Despite staff awareness, the injury was not reported due to assumptions about its cause, contrary to facility policies. This deficiency in reporting placed residents at risk of potential abuse or neglect.
Failure to Provide Timely Incontinence Care and Call Light Response per Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinence care, personal hygiene, and call light response in accordance with residents’ person-centered care plans and stated preferences. Multiple residents with bowel and bladder incontinence, self-care deficits, and cognitive impairment had care plans requiring staff to check and change them on rounds and as needed, keep their skin clean and dry, and conduct routine safety rounds. Despite these documented interventions, staff did not consistently perform timely rounds or respond promptly to call lights, resulting in residents remaining wet or soiled and waiting extended periods for assistance. One resident with severe cognitive impairment, hemiplegia, dementia, and incontinence had a care plan for personal hygiene assistance, turning and repositioning on rounds and as needed, and incontinence care with check and change on rounds and as needed. Nursing notes documented a family complaint that this resident had been left soaking wet with urine for hours, although staff later documented the brief as dry. During observation, this resident was heard crying for help; when the call light was activated, no staff responded for 14 minutes and 9 seconds until a surveyor notified staff at the nursing station. No nursing staff were visible on the hall, and a housekeeper present in the area did not respond to the call light. Another resident with intact cognition and bowel and bladder incontinence, whose care plan required incontinence care every shift and as needed, reported that staff did not check on him every two hours as needed and that sometimes no one checked on him all night. He stated he needed to be changed and repositioned and that he had previously voiced these concerns to nursing staff without improvement. A resident with vascular dementia, diabetes, and frequent bladder incontinence, whose care plan required monitoring for incontinence every 2–3 hours and as needed with application of skin barrier, reported that it took staff 30–45 minutes on different shifts to answer call lights for changing. Her responsible party stated that it typically took 45 minutes to an hour for call lights to be answered and that staff often said they would return but did not. A resident with hemiparesis, frequent bladder incontinence, and a care plan requiring check and change on rounds and as indicated, toileting/incontinence care with assistance, and keeping skin clean and dry with barrier cream, reported that her call light was not answered promptly. She described an incident where she was wet, called for help, and waited one hour and 26 minutes for a CNA to respond. She also reported waiting 15–30 minutes for assistance to get up from the commode, despite needing help due to left leg weakness and pain. Another resident with paraplegia, bowel and bladder incontinence, and a history of sacral moisture-associated skin damage, whose care plan required check and change on rounds and as needed and keeping skin clean and dry with barrier cream, reported developing bed sores on her bottom from not being changed in a timely manner. She stated that the sore had been healing but broke out again when she was not changed, including an episode where she was not changed overnight when one CNA had the whole hall, and she sometimes waited 7–8 hours during night shifts in her own waste. This same resident reported that when she pressed the call light, nobody came, and staff sometimes entered, turned off the call light, and said they would return when they had time, with actual waits of 30 minutes to an hour. Observation of her peri care revealed pink, dry skin breakdown around the sacrum and medial thighs. Multiple CNAs, an LVN, and an RN confirmed that call lights were expected to be answered immediately or within a few minutes, that rounds should be conducted every two hours, and that unanswered call lights and delayed incontinence care could lead to falls and skin breakdown. They acknowledged that not answering a call light for extended periods, such as over an hour, could be considered neglect. Despite a written policy and prior in-services emphasizing timely response to call lights and resident needs, staff interviews and resident/family reports showed that call lights were frequently unanswered for prolonged periods and that routine rounds and incontinence care were not consistently performed as care planned.
Unattended, Unlocked Medication Cart Accessible in Lobby
Penalty
Summary
Surveyors identified a deficiency related to improper storage and security of medications when one of three medication carts reviewed was found unattended, unlocked, and accessible in the main lobby area. During an observation, the medication cart assigned to the 300 hall was located in an unsecured public area with the locking mechanism protruding outward, allowing the surveyor to open drawers and take photographs without being noticed by the RN or LVN on duty. The cart contained drugs and biologicals that were not secured in accordance with facility policy and professional standards, and it was accessible to staff, residents, and passers-by. In interviews, the RN stated the cart belonged to the LVN assigned to the 300 hall and acknowledged that residents could access the cart and take medications not intended for them. The RN also stated she was the charge nurse and supervisor on duty and responsible for ensuring medication carts remained locked. The DON stated that medication carts were supposed to be locked at all times with no exceptions and that all nurses should have known this practice, referencing an existing facility policy on medication cart security. The LVN, who had worked at the facility for 15 or 16 years and was responsible for the 300 hall cart, acknowledged that policy required carts to remain locked at all times because someone could access them, and confirmed that residents were at risk of taking medications not prescribed to them. The administrator similarly stated that medication carts were to be locked at all times when not in use and that the assigned nurse, as well as any staff or management who observed an unlocked cart, were responsible for ensuring its security. Review of the written policy confirmed that medication carts and their contents were to be kept closed, secured, and/or in line of sight when not in use.
Failure to Provide Written Notice Before Resident Room Change
Penalty
Summary
The facility failed to provide written notice to a resident and her responsible party (RP) prior to changing the resident’s room assignment. The resident, an elderly female with severe cognitive impairment (BIMS score of 3), multiple diagnoses including idiopathic normal pressure hydrocephalus, Alzheimer’s disease, and adult failure to thrive, was moved to a new room due to a non-functioning bathroom in her previous room. The move was discussed verbally with the RP by the Director of Nursing (DON) and Administrator (ADM), but no written notification was provided, and the RP did not have the opportunity to see the new room before the move occurred. Interviews with facility staff, including the social worker (SW), assistant director (AD), and licensed vocational nurse (LVN), confirmed that the facility’s practice was to notify residents and families of room changes verbally, not in writing. The SW and AD stated that verbal consent was documented in the electronic health record, and the SW was generally responsible for coordinating room changes. The ADM and DON both indicated that the urgency to move the resident was due to a directive from a state surveyor to ensure the resident had access to a working bathroom, but acknowledged that written notice was not provided as required. The facility’s policy and procedure for resident rights, as reviewed, did not specify the requirement for written notification prior to room changes, and staff interviews confirmed that written notice was not part of the facility’s standard process. The lack of written notice and documentation of the reason for the room change constituted a failure to honor the resident’s right to receive written notice before a change in room or roommate, as required by regulation.
Failure to Enforce Smoking Policy and Ensure Smoking Safety
Penalty
Summary
The facility failed to establish and implement policies regarding smoking, smoking areas, and smoking safety in accordance with applicable laws and regulations, specifically as it relates to both residents and staff. An incident was observed in which a certified nursing assistant (CNA) was seen on video using what appeared to be a vape device while providing care to a resident in the restroom, with another CNA present. The resident involved had significant medical conditions, including normal pressure hydrocephalus, Alzheimer's disease, adult failure to thrive, hyperlipidemia, hypertension, and depression, and was assessed as cognitively impaired and at risk for falls. The resident required assistance with transfers and toileting due to generalized weakness and poor balance. The facility's policy stated that team members were only permitted to smoke in approved designated areas and that smoking, including the use of electronic devices, was prohibited in all other areas, especially where it could create hazardous or unsafe conditions. Despite this policy, the CNA admitted to using a vape device while caring for the resident, which was corroborated by video evidence and interviews. The resident was not aware of the incident until informed by a family member who had seen the video footage. The facility's records indicated that this was the CNA's first such incident and that there had been no prior grievances filed against her.
Failure to Ensure Safe, Clean, and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided excerpt, nor are there direct observations or events described beyond the general statement of noncompliance with the requirement.
Failure to Label and Date Food Items in Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to properly label and date food items stored in the kitchen refrigerator. Specifically, salad greens in a metal container covered with plastic wrap, pasta noodles in a metal container covered with tinfoil, and a yellow, non-opaque liquid with chunks in a metal container covered with tinfoil were all found without labels indicating the date opened or discard by dates. During interviews, both the Dietary Manager and interim Administrator confirmed that all kitchen staff were responsible for labeling and dating food items, and acknowledged that the lack of labeling could result in staff not knowing when food had spoiled. Review of the U.S. Public Health Service Food Code confirmed that ready-to-eat foods must be discarded if not properly dated.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with severe cognitive impairment, specifically in the area of pain recognition and management. The resident, who had a history of cerebral infarction, epilepsy, repeated falls, and dementia, was unable to verbalize his pain levels due to his cognitive condition. Despite this, staff consistently used a numerical pain scale, which was inappropriate for the resident's condition, as he could not communicate his pain level effectively. The resident experienced multiple falls in January and February, during which staff failed to accurately assess his pain levels. The facility's staff, including RNs and LVNs, used numerical pain assessments instead of the pain ad assessment, which is designed for residents who cannot verbalize their pain. This led to repeated documentation of a pain level of 0/10, despite the resident's inability to communicate his pain accurately. Interviews with staff revealed a lack of consistent training and understanding of the appropriate pain assessment tools for cognitively impaired residents. The deficiency was further highlighted by the facility's lack of a policy on the accuracy of assessments, as well as inconsistent in-servicing on pain recognition and management. Staff interviews indicated that while some were aware of the need to use the pain ad assessment for non-verbal residents, this was not consistently applied in practice. The failure to use the correct pain assessment tool placed the resident at risk of not receiving timely and effective pain management, as evidenced by the resident's multiple falls and subsequent injuries.
Failure to Provide Assistive Device Leads to Coffee Spill
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents. A resident, who had a history of tremors and spastic movements, was not given a modified cup with a lid when served coffee. Instead, the resident was given coffee in a standard mug, which led to the resident spilling the hot coffee onto her hand and the table. This incident occurred because the nurse aide in training (NAIT) was not aware of the resident's need for an assistive device and did not know how to access the Kardex to verify the resident's requirements. The resident involved had a complex medical history, including unspecified psychosis, a history of traumatic brain injury, seizures, epilepsy, muscle weakness, and cognitive communication deficit. The resident's care plan specifically required the use of a modified cup with a lid to prevent accidents due to her tremors and altered movements. Despite this, the NAIT, who was still in training and unfamiliar with the resident, failed to provide the necessary assistive device, resulting in the spill. Interviews with staff revealed that the NAIT relied solely on meal tickets to determine the need for assistive devices and was not trained to access the Kardex. The Director of Clinical Education and the Director of Nursing confirmed that the expectation was for staff to check both meal tickets and the Kardex to ensure residents received the appropriate assistive devices. The failure to provide the required assistive device could have resulted in injury to the resident, highlighting a gap in staff training and supervision during meal services.
Failure to Maintain Accurate Narcotic Count Records
Penalty
Summary
The facility failed to maintain accurate records and periodic reconciliation of controlled drugs, as evidenced by missing documentation on Narcotic Count Sheets for several shifts across different halls. Specifically, the Change of Shift Narcotic Counts for the 100 Hall on February 5, 2025, revealed missing documentation for the night shift on February 4, 2025. Similarly, the 200/300 Hall count sheet showed missing documentation for the night shift on February 3, 2025, and both day and night shifts on February 4, 2025. The 600 Hall count sheet lacked documentation for the night shift on February 1, 2025, and the 700 Hall count sheet was missing documentation for the night shift on February 1, 2025, and February 3, 2025. Interviews with the Director of Nursing (DON) and the WFM revealed that the facility's expectation was for the off-going and on-coming nurses to count narcotics together and sign the Narcotic Count sheet. Despite training provided through online avenues and a three-day in-person orientation, the facility did not ensure compliance with these expectations. The DON acknowledged that missing signatures could lead to drug diversion, and the Pharmacy consultant's audits were intended to identify trends. However, the lack of consistent adherence to narcotic count procedures was evident, as demonstrated by the missing documentation on the count sheets.
Deficiency in Food Quality and Preparation
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. During an observation of a lunch test tray, the meal was found to be lukewarm, unappetizing in appearance, and lacking in seasoning and flavor. The beef stroganoff pasta noodles were overcooked and mushy, the gravy was greasy and watered down, and the green beans were unseasoned. Multiple residents expressed dissatisfaction with the meal, noting that it was not appealing, lacked flavor, and was served cold. Some residents resorted to ordering fast food or alternative menu items due to the poor quality of the meal. The facility also failed to follow the puree diet recipe, specifically for scrambled eggs, due to the absence of proper measuring equipment. The dietary staff had to guess the amount of thickener to add, as there was no tablespoon available, and the recipe manual lacked a recipe for oatmeal. This led to uncertainty in preparing pureed foods, potentially affecting the nutritional intake of residents on puree diets. The dietary manager acknowledged the lack of proper equipment and the absence of a puree oatmeal recipe, which could result in inconsistencies in food preparation. Interviews with the dietary manager and administrator revealed expectations for a fine dining experience for residents, with food that is flavorful, well-presented, and palatable. However, the facility did not have a specific policy related to food palatability, and the administrator was unable to provide a protocol for following recipes and preparing food. The lack of proper equipment and adherence to recipes could lead to residents not receiving the correct consistency of pureed food, potentially impacting their nutritional needs.
Failure to Maintain Dignity During Meal Times
Penalty
Summary
The facility failed to treat residents with respect and dignity, particularly during meal times, which affected four residents. Resident #30, Resident #50, and Resident #108 were not assisted with feeding in a dignified manner. A CNA was observed feeding these three residents simultaneously by moving between them on a rolling chair, which was not conducive to maintaining their interest in eating. This method of feeding was contrary to the facility's training, which emphasized feeding one resident at a time to ensure proper encouragement and attention. Resident #190 experienced a delay in receiving her meal, which compromised her dignity. She was left waiting for approximately 45 minutes after her tablemate was served, causing her distress and anxiety about not receiving her food. The LVN on duty acknowledged that the meal tray was missing and had to be retrieved from the kitchen, indicating a lapse in the meal service process. This oversight led to Resident #190 observing others eat while she remained without food, highlighting a failure in the facility's responsibility to ensure timely meal service. Interviews with staff, including the CNA, LVN, Director of Nurses, and the Administrator, revealed a lack of adherence to the expected standards of care during meal times. The CNA admitted to the difficulty of feeding multiple residents simultaneously and acknowledged the need for encouragement to maintain residents' interest in eating. The LVN and Administrator recognized the dignity issue and the expectation for one-on-one feeding. However, the Director of Nurses suggested that feeding more than one resident was not unusual, despite the potential negative impact on residents with dementia. The absence of a policy on serving meals in the dining room further underscores the facility's deficiency in maintaining residents' dignity during meal times.
Deficiencies in Kitchen Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. During an observation, a dietary staff member, DC K, did not practice proper hand hygiene while preparing pureed meals. DC K was seen touching various potentially contaminated surfaces, such as her clothes, a menu manual, and a plastic bag, without washing or sanitizing her hands before handling food. This lack of hand hygiene was acknowledged by DC K, who admitted to not washing her hands during the entire food preparation process, potentially leading to food contamination. Additionally, another dietary staff member, DC L, was observed not wearing a beard guard correctly while standing over a food preparation table. His beard guard was positioned under his chin, leaving his facial hair exposed. DC L acknowledged the improper use of the beard guard and recognized the potential for hair to fall onto food, which could lead to contamination. The Dietary Manager confirmed that all staff with facial hair were expected to wear beard guards and that the failure to do so could result in food contamination. The facility's Employee Sanitation Policy requires staff to wear hair restraints and practice hand hygiene to prevent contamination. However, the in-service training records for hand hygiene and beard guard use were not provided at the time of the survey exit. The Administrator and Dietary Manager both acknowledged the potential for cross-contamination due to these lapses in protocol, although they could not determine the specific health risks without knowing the type of bacteria involved.
Failure to Provide Adequate Assistance and Qualified Feeding
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for two residents. For Resident #400, the Assistant Director of Nursing (ADON A) observed the resident sliding out of bed and did not provide the necessary assistance to help the resident with bed mobility. Surveillance footage showed Resident #400 attempting to sit up and calling for help, but ADON A left the room without assisting. The resident's family member had to call the nurses' station for help, and it took 10 minutes for someone to assist the resident back into bed. The Director of Nursing (DON) and Administrator acknowledged that the staff should have provided assistance, and the failure to do so could have resulted in a fall. Resident #400 was an elderly female with a history of cerebral infarction, acute pulmonary edema, acute kidney failure, and other conditions that required assistance with activities of daily living (ADL). Her care plan indicated she needed one-person assistance for bed mobility and repositioning. Despite this, ADON A did not provide the necessary help, and the family member expressed dissatisfaction with the facility's response time and care, leading to the resident's discharge. For Resident #188, the facility failed to ensure a qualified staff member fed the resident. An Activity Assistant, who was not trained or certified to feed residents, was observed feeding Resident #188 in the dining room. The Activity Assistant admitted to not being qualified and expressed concerns about the potential for choking. The DON and Administrator confirmed that only qualified staff, such as CNAs, nurses, or speech therapists, should feed residents. The lack of qualified staff during feeding times posed a risk of aspiration for Resident #188, who had a self-care deficit and required assistance with eating.
Inadequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, leading to poor hygiene and potential health risks. Resident #30, a female with Alzheimer's disease and severe cognitive impairment, was observed with a blackish/brownish substance under her fingernails and uneven nail edges. Her care plan indicated she required assistance with personal hygiene, but her nails were not properly maintained, which could lead to hygiene issues and potential health risks. Similarly, Resident #80, who also had severe cognitive impairment and required substantial assistance with personal hygiene, was found with similar nail conditions. Her care plan specified that her nails should be checked, trimmed, and cleaned on bath days and as needed. However, observations revealed that her nails were not smooth, and there was a blackish/brownish substance underneath them, indicating a lack of proper nail care. Interviews with CNAs and the ADON revealed that CNAs were responsible for nail care, except for residents with diabetes, whose nails were managed by nurses. Despite being in-serviced on nail care, staff members did not recall the training dates and were unaware of any refusals of nail care by the residents. The Director of Nurses confirmed that all residents should receive nail care during showers and as needed, and any changes in nail conditions should be reported to the nurse supervisor.
Failure to Accommodate Dietary Needs
Penalty
Summary
The facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for two residents. Resident #50, who has Alzheimer's disease and other cognitive impairments, was served pureed taco beef meat despite her meal ticket indicating a dislike for beef. The CNA responsible for feeding her did not notice the meal ticket, and the LVN who checked the meal trays did not pay attention to the residents' likes and dislikes. Resident #241, who has multiple diagnoses including encephalopathy and type 2 diabetes, was served food items containing gluten despite having a documented allergy to gluten. Her meal ticket clearly stated her allergies, but she was still served oatmeal, a blueberry muffin, a dinner roll, and egg noodles, none of which were gluten-free. The dietary manager confirmed that the facility did not have gluten-free products in stock prior to the incident. Interviews with staff revealed a lack of awareness and adherence to the residents' dietary needs. The RN and CNA involved in meal service were not fully aware of the residents' dietary restrictions, and the dietary manager admitted that gluten-free products were not available. The Director of Nursing stated that the facility had gluten-free items in stock, but this was contradicted by the dietary manager. The failure to accommodate these dietary needs placed the residents at risk of consuming allergens and receiving meals that did not align with their preferences.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with an indwelling urethral catheter. The resident, a woman with a history of Type 2 Diabetes Mellitus and Neuromuscular Dysfunction of the Bladder, was observed receiving perineal and catheter care from two CNAs who did not adhere to the required EBP protocols. Despite a sign indicating EBP outside the resident's room, the CNAs only wore gloves and did not use gowns during the care process, which is a necessary component of EBP to prevent the spread of infections. The deficiency was further compounded by a lack of communication and documentation errors. One of the CNAs was unaware of the resident's EBP status, mistakenly believing that the precautions were no longer necessary due to the healing of a sacral wound. This misunderstanding was exacerbated by the absence of EBP information in the resident's Kardex, a tool used by staff to verify care instructions. The Director of Nursing acknowledged that staff should be informed of precautionary measures through the Kardex, highlighting a gap in the facility's infection control practices.
Failure to Notify Responsible Party of Resident's Hospitalization
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) of a resident when there was a significant change in the resident's physical status. Specifically, the facility did not inform the RP when the resident was sent to the hospital for low blood pressure during a dialysis treatment. The resident, who had end-stage renal disease and unspecified dementia with a severe cognitive impairment, was not able to communicate effectively about his condition. The lack of notification was confirmed through interviews and record reviews, which showed no documentation of a call made to the family on the day of the incident. Interviews with the resident's RP, the Regional Nurse, LVN A, and the Administrator (ADM) revealed that the facility's staff did not follow the expected protocol of notifying the RP about the resident's hospital transfer. LVN A admitted to not contacting the RP, mistakenly assuming that the dialysis center would handle the notification. This oversight was acknowledged by both the Regional Nurse and the ADM, who confirmed that it was the facility's responsibility to inform the RP to ensure their involvement in the resident's care plan. The facility's policy on changes in resident condition, which mandates notifying the resident, attending physician, and RP, was not adhered to in this instance.
Medication Errors Lead to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, which led to an Immediate Jeopardy situation. Upon admission from the hospital, the resident's order for insulin was not instated, despite having a diagnosis of type II diabetes. Additionally, the resident was administered two anti-seizure medications, Lacosamide and Divalproex Sodium, without having a diagnosis for seizures, epilepsy, or a psychiatric/mood disorder. This resulted in a sudden change in the resident's consciousness and responsiveness, necessitating a transfer to the hospital. The resident, a female with a history of stroke, type II diabetes, and end-stage renal disease, was admitted to the facility with hospital discharge orders that included insulin administration and blood sugar monitoring. However, these orders were not accurately transcribed into the facility's records. Instead, the resident received medications for seizures, which were not part of her medical history or hospital discharge instructions. The resident's blood sugar levels were recorded as significantly elevated, yet the insulin order was not implemented until after she was sent to the hospital. Interviews with facility staff revealed a lack of proper medication reconciliation and verification of hospital discharge orders. The resident's nurse practitioner and medical doctor indicated that the administration of anti-seizure medications without a proper diagnosis could lead to sedation and other adverse effects, which likely contributed to the resident's hospitalization. The facility's failure to accurately transcribe and administer medications as per the hospital's discharge orders placed the resident at risk and resulted in a critical incident.
Removal Plan
- Licensed nurse should conduct appropriate medication reconciliation as well as blood glucose monitoring orders in relation to the hospital discharge orders and ensure that all hospital discharge orders to include medications, treatments and blood glucose monitoring orders are reviewed and confirmed with the accepting attending physician upon admission.
- Post reconciliation of the medication/treatment/blood glucose monitoring order, the licensed nurse should review each medication and/or treatment and blood glucose monitoring orders as well as insulin orders, to ensure that they are accurately transcribed as per the hospital discharge orders as well as any new orders provided by the attending physician/medical provider are accurately transcribed into the electronic health record.
- Clinical leadership/assigned licensed nurse will conduct a post admission review of all new admission/re-admission orders to include but not limited to insulin orders, blood glucose monitoring orders, correct medication orders and treatment orders against the hospital discharge order to validate the accuracy of medication reconciliation and proper transcription of physician orders. Should any discrepancies be identified, the licensed nurse should immediately report the discrepancy, clarify with the attending physician/medical provider, and complete a medication error report as indicated.
- Director of Clinical Operations/Assistant Director of Nursing initiated in-service training for licensed nurses regarding the process for medication reconciliation, confirming orders upon admission/re-admission and transcribing orders into the electronic health record.
- Licensed nurses will complete a test to validate the process for proper medication reconciliation, confirming orders upon admission/re-admission and transcribing orders into the electronic health record to validate competency of the facility's expected practices.
- Director of Clinical Operations/Assistant Director of Nursing will conduct 100% audit of all current in-patient new admissions/re-admissions' medication and treatment orders reconciliations to validate accuracy of the admission/re-admission orders entered into the electronic medical record.
- Director of Clinical Operations/Administrator suspended the licensed nurse pending investigation who was responsible for completing an accurate medication reconciliation and accurately entering the correct hospital discharge orders after confirming the medication and treatment orders with the accepting medical provider upon admission.
- Director of Clinical Operations/Assistant Director of Nursing will provide the same in-service trainings with all newly hired licensed nurses going forward as a part of the on-boarding process for nurses.
- Director of Clinical Operations/Assistant Director of Nursing will ensure all licensed nursing staff will be re-educated to include any licensed nurse on leave/agency/PRN staff. All licensed nurses will be in-serviced prior to assuming next shift. Director of Clinical Operations/Administrator will ensure administrative nursing staff is available to provide in-service/education prior to the licensed nurses working their next assigned shift.
- Director of Clinical Operations/Assistant Director of Nursing will conduct random weekly audit of new admission/re-admission physician orders to validate the accuracy of the medication reconciliation and transcription process of the physician/medical provider confirmed orders within the E.H.R against the hospital discharge orders to validate medication, insulin and treatment accuracy.
- Director of Nursing/Assistant Director of Nursing will conduct daily reviews during clinical start-up meeting review of new/re-admission orders, progress notes, and the 24-hour report to ensure that appropriate interventions and/or all needed follow up has been assigned.
- Administrator, Director of Clinical Operations, and the Medical Director conducted an Ad Hoc QAPI meeting to review the identified deficient practice and plan of removal (corrective action plan) implemented.
Failure to Provide Timely Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers for a resident who was admitted with a hip fracture requiring surgery. Upon admission, the resident had shearing to her sacrum, which was not treated promptly, leading to the development of a stage III pressure ulcer. The resident's admission care plan indicated she was at risk for skin impairment due to frail and fragile skin and decreased mobility, yet appropriate wound treatment orders were not instated until several days after her admission. The resident's hospital discharge paperwork noted redness to the sacrum, and the facility's admission assessment identified an open area to the buttock and shearing. Despite these findings, the facility did not implement standing wound treatment orders immediately upon admission. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's wound care needs. The Wound Care Nurse (WCN) was not notified of the resident's condition, and the admitting nurse did not initiate standing treatment orders, resulting in a delay in care. The facility's policy required that new admissions with skin impairments have treatment orders initiated at the time of admission. However, the admitting nurse failed to follow this protocol, and the resident's wound care was not addressed until the WCN assessed the wound days later. This oversight placed the resident at risk for further deterioration of the wound, infection, and pain, highlighting a systemic issue in the facility's wound management practices.
Facility Lacks Certified Activities Directors
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by their policy and job description. The Activities Director (AD) was recently hired and previously worked as a Certified Nursing Assistant (CNA). Although she was enrolled in an AD certification and training program, she was not yet certified. Additionally, the facility's Administrator (ADM) confirmed that neither the AD for the secured memory care unit nor the AD for the rest of the facility's residents were certified as qualified therapeutic recreation specialists or certified activity professionals. The facility's job description for the Activities Director position required current certification as a Certified Activities Director. Furthermore, the facility's policy on the activities program, dated January 2023, stipulated that the program should be directed by a qualified professional who is either a certified therapeutic recreation specialist or a certified activity professional, and who is licensed or registered by the state, if applicable. The ADM acknowledged that the lack of certified ADs resulted in fewer activity opportunities for the residents, which could potentially impact their quality of life.
Failure to Notify Resident Representative of Injury
Penalty
Summary
The facility failed to notify the resident representative (RP) of an accident involving a resident that resulted in an injury with the potential for requiring physician intervention. Specifically, the facility did not inform the RP of a resident's black eye, which was observed by staff on 10/27/24 at 1:30 PM, until later that evening at 7:39 PM. Additionally, the RP was not informed of any incidents that occurred on 10/25/24 until 10/27/24, indicating a delay in communication that could affect the resident's quality of life and safety. The resident involved was a female with severe cognitive impairment, as indicated by a BIMS score of 6, and had multiple diagnoses including unspecified dementia and generalized muscle weakness. Her care plan noted communication difficulties due to her cognitive impairment and language barrier, requiring frequent checks by nursing staff. Despite these needs, there were no interventions in place to ensure timely notification of the RP or family in the event of an incident. Interviews with staff revealed a lack of clarity and consistency in the notification process. Several staff members, including LVNs and CNAs, were unsure of the exact procedures for notifying families and the importance of doing so promptly. The facility's policies on changes in resident condition and abuse reporting emphasize the need for immediate notification of the resident's physician and family, yet these protocols were not followed, as evidenced by the delayed communication with the resident's RP.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident who was dependent on staff assistance for activities of daily living (ADLs), except for eating. The resident's wheelchair was observed to be unclean, with brown-colored spots, a foul odor, and dried-up substances on the armrests, seat, and wheel. Despite the resident's severe cognitive impairment and communication difficulties, the staff did not ensure the cleanliness of her wheelchair, which could potentially lead to neglect, infection, and a diminished quality of life. Interviews with various staff members revealed a lack of clarity and accountability regarding the cleaning of residents' wheelchairs. Certified Nursing Assistants (CNAs) were generally responsible for cleaning wheelchairs, but there was no consistent oversight or schedule to ensure this task was completed. Some staff members believed the night shift CNAs were responsible, while others thought it was a shared responsibility among all shifts. The Director of Nursing (DON) and other supervisory staff were unaware of the specific condition of the resident's wheelchair and did not have a system in place to monitor the cleanliness of wheelchairs. The facility's policies and position agreements indicated that CNAs and charge nurses were expected to address and report concerns immediately, but this was not effectively implemented. The facility's cleaning and disinfection policy required non-critical surfaces, such as wheelchairs, to be disinfected with an EPA-registered disinfectant, but this was not adhered to in practice. The lack of communication and oversight led to the resident's wheelchair remaining in an unclean state, impacting the resident's dignity and potentially their health.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving a resident who was found with a black eye within the required 24-hour timeframe. The resident, a female with severe cognitive impairment and a history of dementia, was discovered with bruising around her left eye on 10/27/24. Despite multiple staff members being aware of the injury, the incident was not reported to the State Agency (SA) as required by the facility's policies and state regulations. The resident's medical history included severe cognitive impairment, dementia, and a history of falls, which complicated the investigation into the cause of the injury. Interviews with various staff members, including CNAs, LVNs, and the DON, revealed a lack of clarity and communication regarding the reporting process for injuries of unknown origin. Several staff members, including the DON and ADM, assumed the injury might have been caused by the resident's bedside table due to her history of nodding off at the table. However, no definitive cause was determined, and the facility's decision not to report the incident was based on assumptions rather than concrete evidence. The facility's policies required reporting injuries of unknown origin, but the staff did not follow these protocols, leading to a deficiency in reporting. The facility's documentation and interviews indicated that no in-services or additional training were provided to staff following the incident, which may have contributed to the lack of proper reporting. The ADM and DON believed that the injury was not suspicious or of unknown origin, and therefore did not report it to the SA. This decision was contrary to the facility's policies, which required reporting all unexplained injuries to ensure resident safety. The failure to report the incident in a timely manner placed residents at risk of potential abuse or neglect.
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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.
Trusted data from CMS and state health departments
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