Hearthstone Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Round Rock, Texas.
- Location
- 401 Oakwood Blvd, Round Rock, Texas 78681
- CMS Provider Number
- 455771
- Inspections on file
- 30
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hearthstone Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities exhibited ongoing physical and verbal aggressive behaviors documented in MDS assessments and nursing progress notes, including hitting staff, throwing items, and pushing another resident. Despite these documented behaviors, the comprehensive care plan did not include aggression as a problem area or outline related goals and interventions. The DON, ADON, and ADM acknowledged that the care plan should have been updated in accordance with the facility’s care planning policy, which requires the IDT to revise care plans as resident conditions and behaviors change.
A resident with a newly diagnosed Major Depressive Disorder was not referred for a Level II PASARR evaluation after a significant change in condition. Despite facility policy and staff acknowledgment that a new diagnosis should trigger a PASARR review, the required referral was not completed, and the resident was not listed among PASARR-positive individuals.
A resident with a diagnosis of Major Depressive Disorder and a positive Level II PASARR screening did not receive a timely referral for specialized services, as required. Despite recommendations and approvals for therapies, the facility failed to notify the appropriate authorities and initiate PASARR services within the mandated timeframe, as confirmed by staff interviews and record review.
A facility failed to include hospice services in a resident's care plan, despite documentation of hospice admission in the resident's records. The MDS nurse, responsible for care plans, was unaware of this omission, which could delay necessary care. The resident, an elderly female with multiple health issues and severe cognitive impairment, was not care planned for hospice services, contrary to facility policy.
The facility failed to maintain proper infection control practices during medication administration, as observed with two residents. The MA did not perform hand hygiene or sanitize the blood pressure cuff between residents, increasing the risk of infection. Both residents had significant medical conditions, making them vulnerable to infections. Interviews confirmed the facility's policies on hand hygiene and equipment sanitation, which were not followed during the incidents.
A resident with severe cognitive impairment and a history of bipolar disorder was slapped on the head by a CNA during a wheelchair transfer in the facility's lobby. The incident was witnessed by the receptionist and a van driver from another facility. The resident was assessed with no apparent injury, and the CNA was removed from duty and terminated. Local law enforcement found probable cause for assault, resulting in a warrant for the CNA's arrest.
A facility failed to document follow-up observations for a resident with severe cognitive impairment and a tracheostomy stoma, who experienced uncontrolled coughing and respiratory distress. Despite interventions ordered by the NP, the resident's condition did not improve significantly, and he was sent to the ER. The nurse did not document changes in the resident's condition, and the facility's policy lacked guidance on nursing documentation.
A resident with severe cognitive impairment was observed spitting out her morning medication, which was not confirmed by the administering LVN. The LVN was unaware of the resident's history of pocketing/spitting out medication and did not ensure consumption, contrary to facility policy.
Failure to Update Care Plan for Ongoing Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s person-centered comprehensive care plan to reflect current aggressive behaviors. The resident, a 75-year-old female admitted with diagnoses including severe unspecified dementia without behavioral disturbance, type 2 diabetes mellitus, delusional disorder, depression, and hypertension, had an MDS assessment showing a BIMS score of 2, indicating severe cognitive impairment. The same MDS documented physical behavioral symptoms directed toward others, verbal behavioral symptoms, and other behavioral symptoms occurring multiple days during the look-back period. Despite these documented behaviors, the comprehensive care plan dated 10/31/2025 did not include an aggressive behavior problem area, related goals, or interventions. Nursing progress notes documented multiple episodes of escalating aggressive behavior over several weeks. On 9/17/2025, staff documented the resident throwing items off the counter, hitting staff, cussing at staff, throwing offered water on the floor, and being on 1:1 observation. On 9/24/2025, notes indicated physically aggressive behavior toward staff and that the resident pushed another resident down when touched, with reports of increased aggressive behaviors during the day. On 10/3/2025, documentation showed the resident was physically aggressive toward nursing staff when they attempted to redirect her. These entries demonstrated ongoing and increasing aggressive behaviors that were recorded in the nursing notes but not incorporated into the resident’s care plan. Interviews with facility leadership confirmed that the care plan was not updated to reflect the resident’s aggressive behaviors despite policy requirements. The DON stated she was familiar with the Care Planning policy, acknowledged that the MDS coordinator was responsible for completing care plans with input from the IDT, and agreed that the resident’s aggressive behaviors should have been documented in the care plan but did not know why this had not occurred. The ADON reported recent training on the Care Plans policy and stated that the resident’s care plan needed to be updated as soon as behaviors were reported by staff. The ADM also confirmed prior training on care planning, stated that the resident’s physical aggression should be documented in the care plan as soon as it was noticed or as soon as possible, and noted that while the behaviors were documented in nursing progress notes, they were not reflected in the care plan. Review of the facility’s Care Planning policy showed that care plans must incorporate identified problem areas, risk factors, measurable goals, and be revised as residents’ conditions change, which did not occur in this case.
Failure to Refer Resident for Level II PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR (Preadmission Screening and Resident Review) following a new diagnosis of Major Depressive Disorder. Record review showed that the resident was admitted with no prior diagnosis of mental disorder, intellectual disability, or related condition, as indicated by a negative Level I PASARR screening. However, subsequent documentation, including the resident's face sheet, MDS record, and care plan, confirmed a diagnosis of Major Depressive Disorder. Despite this significant change in condition, there was no evidence that the resident was referred for a Level II PASARR evaluation, nor was the resident listed among PASARR-positive residents. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, confirmed that the facility's policy requires a new PASARR screening upon a significant change in condition or new diagnosis of mental illness, intellectual disability, or related condition. Staff acknowledged that failure to conduct an accurate PASARR screening could result in residents not receiving appropriate services. The MDS Coordinator was identified as responsible for PASARR screenings, but the required referral for Level II PASARR was not completed for the resident after the new diagnosis.
Failure to Timely Refer Resident for PASARR Specialized Services
Penalty
Summary
The facility failed to notify the appropriate state mental health or intellectual disability authority promptly after a significant change in the condition of a resident with a mental illness, as required for PASARR (Preadmission Screening and Resident Review) processes. Record review showed that a male resident with a diagnosis of Major Depressive Disorder had a positive Level II PASARR screening and was recommended for specialized services, including physical, occupational, and speech therapy. Despite these recommendations and approvals for services, the facility did not ensure that the resident was referred to PASARR services within the required timeframe. The care plan did not indicate whether the resident received PASARR services, and documentation revealed the resident had been PASARR positive for several years. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, confirmed that the referral for PASARR services was not sent within the required 20-day period following the IDT meeting. Staff acknowledged that this delay or omission could result in the resident not receiving necessary specialized services. Facility policy required notification to the Local Intellectual and Developmental Disability Authority (LIDDA) within two days of admission for positive PASARR screenings, but this process was not followed for the resident in question.
Failure to Include Hospice Services in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was receiving hospice services. Despite the resident's admission to hospice being documented in the physician's orders and the Admission MDS assessment, the care plan did not reflect this critical aspect of the resident's care. The MDS nurse, who was responsible for completing care plans, acknowledged awareness of the resident's hospice status but was unaware that the care plan did not include hospice services. This oversight could potentially lead to a delay in care or interventions for the resident. The resident in question was an elderly female with multiple diagnoses, including diabetes, hyperlipidemia, dementia, and hypertension, and was severely cognitively impaired with a BIMS score of 07. The Director of Nursing (DON) confirmed that the MDS nurse was responsible for care planning hospice services and that the omission of hospice services from the care plan was not in line with the facility's policy. The facility's policy mandates that care plans include measurable objectives and timeframes to meet the resident's needs, and the failure to include hospice services in the care plan was a deviation from this policy.
Inadequate Infection Control Practices During Medication Administration
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper hand hygiene and equipment sanitation practices observed during medication administration for two residents. The medication aide (MA) did not perform hand hygiene or sanitize the blood pressure cuff between residents, which is a critical step in preventing the transmission of communicable diseases and infections. This oversight was observed during the administration of medications to two residents, both of whom had significant medical conditions that increased their vulnerability to infections. Resident #17, a female with severe cognitive impairment and multiple diagnoses including encephalopathy, acute respiratory failure, diabetes, pneumonia, anxiety, and major depressive disorder, was one of the residents affected. Her care plan included a focus on resolving an acute infection without complications. The MA used an unsanitized blood pressure cuff on Resident #17 and failed to perform hand hygiene before and after administering medications. Similarly, Resident #44, who had moderate cognitive impairment and a history of dementia, depression, high blood pressure, and urinary tract infections, was also at risk. Her care plan highlighted the risk of infection, particularly COVID-19. The MA repeated the same unsanitary practices with Resident #44, using the same blood pressure cuff without cleaning it and neglecting hand hygiene. Interviews with the MA, DON, RN, and ADM confirmed the facility's policies on hand hygiene and equipment sanitation, emphasizing their importance in infection control, yet these were not adhered to during the observed incidents.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who slapped a resident on the head in the presence of witnesses. The incident occurred in the facility's front lobby while the resident was being transferred to another wheelchair. The resident, who has severe cognitive impairment and a history of bipolar disorder, was reportedly making a kicking movement when the CNA responded by slapping him. This action was witnessed by the facility's receptionist and a van driver from another facility. The resident involved in the incident is an elderly male with a history of cerebral infarction, hemiplegia, hemiparesis, acute respiratory failure, and bipolar disorder. His care plan indicated a severe cognitive impairment with a BIMS score of 0, and he had not exhibited any physical or verbal behaviors prior to the incident. The resident's care plan also noted a self-care deficit and potential for physical aggression due to his bipolar disorder, with specific interventions outlined for staff to manage his behavior. Following the incident, the resident was assessed by a nurse, who found no apparent injury on his head. The facility's administrator, who serves as the abuse and neglect coordinator, was notified, and an investigation was initiated. The CNA involved was removed from duty and subsequently terminated. The incident was reported to local law enforcement, who found probable cause for assault, leading to a warrant for the CNA's arrest.
Failure to Document Follow-Up Observations for Resident with Respiratory Distress
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident with severe cognitive impairment and a tracheostomy stoma. The resident was experiencing uncontrolled coughing and respiratory distress, which was reported by his roommate. LVN C assessed the resident and noted foam-like secretions from the trach, elevated pulse, and complaints of dizziness and tiredness. The nurse contacted the NP on-call, who ordered a nebulizer treatment, suctioning, and monitoring. Despite these interventions, the resident's condition did not improve significantly, and he was eventually sent to the emergency room for further evaluation. The deficiency arose because LVN C did not document follow-up observations or assessments after initiating treatments for the resident's condition. Although the nurse recalled the resident's condition improving temporarily, she failed to record these changes in the progress notes. The DON confirmed that she expected all assessments to be documented to ensure timely and appropriate care. The facility's Change of Condition Policy did not address nursing documentation, contributing to the lack of proper record-keeping.
Failure to Ensure Resident Consumed Medication
Penalty
Summary
The facility failed to ensure that a resident consumed her morning medication, as observed on 04/03/24. The resident, who has severe cognitive impairment and no swallowing disorders, was seen spitting her medication into a trash can. LVN A, who was administering the medication, witnessed the incident but did not confirm the resident's consumption of the medication. LVN A mentioned it was her first day in the Memory Care Unit (MCU) and was unaware of the resident's history of pocketing or spitting out medication. She attempted to mix the medication with apple sauce, which the resident found too tart, and planned to try again with chocolate pudding. The Director of Nursing (DON) from a sister facility stated that the expectation during medication pass is for the nurse or medication aide to ensure that each resident consumes their medication. The facility's Medication and Preparation Administration Policy also requires staff to confirm resident consumption of the medication. The failure to ensure the resident consumed her medication could result in the resident not receiving the intended therapeutic benefits and potentially exacerbating her chronic medical conditions.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
