Heritage At Longview Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Longview, Texas.
- Location
- 112 Ruthlynn Dr, Longview, Texas 75605
- CMS Provider Number
- 455569
- Inspections on file
- 28
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Heritage At Longview Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, positive PASRR status, and a need for a manual wheelchair was identified by the IDT and PCSP as requiring a customized manual wheelchair (CMWC). Facility records and the PASRR Compliance Call Report showed that the NF was required to submit an NFSS request for this specialized service in the LTC Online Portal within 20 business days of the IDT meeting, but the Simple LTC PASRR NFSS Activity Portal History and staff interviews confirmed the request was not submitted until well after the required timeframe. The Director of Therapy, identified by the DON and Administrator as responsible for meeting this deadline, acknowledged the late submission as an oversight, resulting in noncompliance with the facility’s PASRR policy and regulatory timeframes for specialized services authorization.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident at high risk for pressure ulcers developed an unstageable ulcer due to the facility's failure to implement necessary interventions and provide adequate care. Despite being identified as high risk, the resident's skin condition was not properly assessed or documented, and the family was not informed of the new skin breakdown. Staff interviews revealed inconsistencies in wound assessment and treatment, indicating a lack of adherence to facility policies.
A facility failed to properly handle and destroy discontinued controlled medications for three residents who had expired. An LVN improperly disposed of the medications by flushing them down the toilet, contrary to facility policy, which requires handing them over to the DON for destruction with a pharmacy consultant. The LVN was suspended and terminated after a positive drug test.
A resident with a history of cerebral infarction, schizophrenia, and dementia developed a new wound on her buttocks, but the LTC facility failed to notify the physician and the resident's family. Despite the care plan's directives and facility policies requiring notification, the responsible party was not informed until the resident was transferred to the hospital for altered mental status. Interviews confirmed the oversight, highlighting a lapse in communication regarding the resident's condition change.
A facility failed to implement a comprehensive care plan for a resident with a diabetic ulcer, resulting in missed daily dressing changes as per physician orders. The resident, with a history of heart failure and diabetes, did not receive proper wound care for several days, as confirmed by record reviews and family member concerns. Facility staff were unaware of the missed treatments, citing the absence of the treatment nurse.
A resident experienced unmanaged pain due to the facility's failure to effectively manage pain and ensure the proper functioning of a low air loss mattress. Despite having a care plan, the resident's pain was not consistently reported to the physician, and a family member's request for a medication change was not communicated. The unplugged mattress caused severe discomfort until surveyor intervention led to its re-inflation.
A facility failed to maintain food safety standards due to a persistent roof leak in the kitchen, with water dripping near food preparation areas. Staff confirmed the leak had been ongoing for over a year, and repair estimates were obtained but not acted upon. Despite the Administrator's belief that the leak posed no risk, the Dietary Manager expressed concerns about potential food contamination.
Two residents in an LTC facility did not receive their scheduled baths, despite requiring assistance with personal hygiene. One resident, with brain damage and reduced mobility, received only three baths in May and none in early June, while another, with heart failure and limited mobility, received only two baths in May and none in early June. Staff interviews revealed inconsistencies in bathing schedules and documentation, with no recorded refusals from the residents.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by the absence of proper signage and adherence to Enhanced Barrier Precautions for two residents. Staff members did not consistently wear gowns while providing care to residents with urinary catheters and wounds, despite the requirement to do so. Interviews revealed a lack of understanding and inconsistent application of Enhanced Barrier Precautions, leading to potential risks of cross-contamination and infection spread.
A resident with Huntington's disease was inaccurately documented as having bipolar disorder on the MDS, despite no such diagnosis in her chart. The MDS nurse acknowledged the error, which could affect the resident's care. Interviews with staff highlighted the importance of accurate assessments for proper treatment, as per facility policy and federal regulations.
A facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment and multiple medical conditions, including traumatic hemorrhage and vascular dementia. The resident's PASRR positive status, requiring specialized therapies and equipment, was not included in the care plan. Interviews with staff revealed confusion over responsibility for ensuring the care plan reflected the resident's needs, contrary to facility policy.
A resident with COPD and other health issues was found to have a dirty oxygen concentrator filter, despite documentation indicating regular checks. Staff interviews revealed that the responsibility for cleaning the filters was assigned to weekend night shift nurses, but the filter remained unclean for several days. This failure contradicted the facility's policy on maintaining optimal breathing patterns and preventing infections.
A resident with dementia and other health issues had Lantiseptic cream improperly stored on her bedside table, contrary to facility policy. The cream, brought from a hospital stay, was not documented in her treatment records, and staff were unclear if it was a medication. Interviews revealed inconsistencies in understanding and implementing storage protocols, risking misuse or harm.
The facility failed to develop and implement a comprehensive care plan for a resident, omitting fall risk interventions and hospice care needs. The resident, with multiple severe diagnoses and cognitive impairment, experienced a fall resulting in a brain bleed. Staff interviews revealed delays and inconsistencies in updating the care plan, contrary to facility policy.
Failure to Timely Submit PASRR NFSS Request for Customized Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to timely coordinate a PASRR Nursing Facility Specialized Services (NFSS) request for a customized manual wheelchair (CMWC) for a resident with intellectual and developmental disabilities. The resident was an adult male with diagnoses including cerebral infarction, convulsions, and a cognitive communication deficit, and his quarterly MDS showed severe cognitive impairment with a BIMS score of 00 and a need for a manual wheelchair. His care plan documented a positive PASRR status and the expectation that he would receive specialized services recommended by the local authority. A PASRR IDT meeting and Person-Centered Service Plan (PCSP) were completed on 08/18/2025, identifying the need for a new CMWC. The PASRR Compliance Call Report indicated that, based on this IDT date, the NF was required to submit the NFSS form for therapies, including the CMWC, in the LTC Online Portal by 09/12/2025 (within 20 business days of the IDT meeting). Record review of the Simple LTC PASRR NFSS Activity Portal History showed that the NFSS request for the CMWC was not submitted within the required 20 business days. The Director of Therapy stated in interview that the NFSS request for the custom wheelchair was actually submitted on 11/07/2025, which was past the 20-business-day requirement, and described this as an oversight. The DON and the Administrator both stated in interviews that the Director of Therapy was responsible for ensuring the NFSS deadline was met and acknowledged that the deadline had been missed. During observation, the resident was seen seated on a couch with his CMWC next to him, but he was non-verbal and could not be interviewed. The facility’s PASRR policy stated that, after the IDT meeting, the NF must submit information from the IDT meeting on the LTC Online Portal and must submit prior authorization requests for NF specialized services via the NFSS form, which did not occur within the required timeframe for this resident’s CMWC request.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for a resident, leading to the development of an unstageable pressure ulcer. The resident, who was at high risk for pressure ulcers due to severe cognitive impairment, decreased mobility, and incontinence, was not properly assessed or treated for pressure injuries. Despite being identified as high risk on the Braden Scale, the facility did not implement adequate interventions to prevent pressure ulcer development. The resident's care plan included interventions for pressure ulcer prevention, such as educating caregivers, following facility protocols, and providing incontinent care. However, these interventions were not effectively implemented. The facility staff failed to identify and document the presence of an unstageable pressure ulcer on the resident's sacral area. There was a lack of communication and documentation regarding the resident's skin condition, and the family was not notified of the new skin breakdown. Interviews with facility staff revealed inconsistencies in the assessment and treatment of the resident's skin condition. The staff did not perform proper wound assessments, and there was confusion about the presence and severity of the wound. The facility's policies for pressure injury prevention and treatment were not followed, leading to the development of an unstageable pressure ulcer that was only identified after the resident was transferred to the hospital.
Improper Handling and Destruction of Controlled Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the proper handling and destruction of discontinued controlled medications for three residents who had expired. These residents had been receiving hospice care and had various diagnoses, including liver cancer, lung cancer, and prostate cancer. The medications in question included Hydrocodone, Lorazepam, and Morphine Sulfate, which were not removed from the medication cart or destroyed according to facility policy after the residents' deaths. The deficiency was further compounded by the actions of an LVN who, instead of following the proper protocol of handing over the medications to the Director of Nursing (DON) for destruction with the pharmacy consultant, decided to destroy the medications himself by flushing them down the toilet. This action was taken without a witness and without proper documentation, which is against the facility's policy. The LVN admitted to being tired and frustrated, which led to his decision to improperly dispose of the medications. Interviews with the DON and the Administrator revealed that the facility's expectation was for nurses to turn in all discontinued narcotic medications to the DON for proper destruction. The LVN involved was suspended and ultimately terminated after a drug test returned positive results for several substances, and he failed to provide prescriptions for them. The facility's policies clearly outlined the correct procedures for handling discontinued medications, which were not followed in this instance.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to consult with the physician and notify the responsible party when a resident experienced a change in condition. Specifically, the facility did not inform the physician or the resident's family when a new wound was discovered on the resident's buttocks. This oversight was identified during a review of records and interviews, revealing that the resident had a history of cerebral infarction, paranoid schizophrenia, contractures, and dementia, and was at high risk for developing pressure ulcers due to her condition. The resident's care plan included interventions for preventing skin breakdown, such as educating family and caregivers, following facility protocols, and notifying family and caregivers of any new skin breakdown. However, when a CNA informed an LVN of the new wound, the LVN consulted a nurse practitioner but did not notify the resident's family or the physician. The resident's daughter, who was the responsible party, was not informed of the wound until the resident was transferred to the hospital for altered mental status. Interviews with facility staff, including the ADON and the DON, confirmed that the responsible party was not notified of the new wound as required by the facility's policies. The facility's policy on notifying the physician of a change in status and the policy on pressure injury prevention and treatment both emphasize the importance of notifying the physician and family of significant changes in a resident's condition. Despite these policies, the facility failed to communicate the resident's change in condition, leading to a delay in addressing the wound appropriately.
Failure to Implement Care Plan for Diabetic Ulcer
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically in the management of a diabetic ulcer on the resident's left second toe. The care plan required daily dressing changes as per physician orders, but the dressing was not changed for several days, as evidenced by the dressing being dated 2/9/2025 and not changed until 2/12/2025. This lapse in care was confirmed through record reviews, observations, and interviews with the resident's family member, who expressed concern about the lack of adherence to the care plan. The resident, a female with a history of diastolic congestive heart failure, protein calorie malnutrition, and type 2 diabetes mellitus, was admitted to the facility with intact cognition and at risk for pressure ulcers. Despite the physician's orders and the care plan specifying daily treatment, the treatment administration record showed missed treatments on 2/9/2025, 2/10/2025, and 2/11/2025. Interviews with facility staff, including the DON and Administrator, revealed a lack of awareness and accountability for the missed treatments, with explanations citing the absence of the treatment nurse and failure of the charge nurse to complete the wound care.
Inadequate Pain Management and Equipment Oversight
Penalty
Summary
The facility failed to provide adequate pain management for a resident, leading to unnecessary pain and decreased quality of life. The resident, who had a history of muscle spasms and pain, was not effectively managed for pain despite having a care plan that included interventions for pain relief. The resident's pain was not consistently reported to the physician, and a family member's request for a medication change to address muscle spasms was not communicated to the physician by the LVN. Additionally, the resident's low air loss mattress, which was intended to prevent pain and pressure ulcers, was found unplugged and not functioning. This oversight resulted in the resident experiencing severe pain, as he felt like he was lying on a board. The mattress was only plugged back in after surveyor intervention, which significantly alleviated the resident's pain once it was re-inflated. Interviews with staff revealed a lack of communication and follow-through regarding the resident's pain management needs. The resident frequently complained of pain, especially during repositioning and wound care, yet there was no documentation of these complaints being addressed or reported to the physician. The facility's failure to manage the resident's pain effectively and ensure the proper functioning of equipment contributed to the resident's ongoing discomfort.
Persistent Roof Leak in Kitchen Raises Food Safety Concerns
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards due to a persistent roof leak in the kitchen. Observations revealed water dripping from the range hood and nearby ceiling tiles, with the water collecting in buckets placed on the floor. The leak was noted to be ongoing for a significant period, with staff indicating it had been an issue for over a year. The water was observed dripping near food preparation areas, specifically near the deep fryer where chicken was being prepared, raising concerns about potential food contamination. Interviews with staff, including the Dietary Aide, Dietary Manager, Maintenance Supervisor, and Administrator, confirmed awareness of the leak. The Maintenance Supervisor mentioned that repair estimates had been obtained from three roofing companies, but no repairs had been attempted. The Administrator acknowledged the issue was brought to his attention in November 2023, and bids for repairs were received, but corporate had not yet addressed the problem. Despite the Administrator's belief that the leak did not pose a risk to food safety, the Dietary Manager expressed concerns about the possibility of water dripping into residents' food.
Failure to Provide Scheduled Baths for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for two residents who were unable to perform activities of daily living independently. Resident #25, who had diagnoses including brain damage, reduced mobility, and depression, required substantial assistance with bathing. Despite being scheduled for baths three times a week, documentation showed that Resident #25 received only three baths in May 2024 and none in early June 2024. Interviews with Resident #25 confirmed infrequent bathing, and there was no documentation of refusal to bathe. Similarly, Resident #43, who had diagnoses including heart failure, depression, and reduced mobility, required partial assistance with bathing. The resident was scheduled for baths on Mondays, Wednesdays, and Fridays, but records indicated only two baths in May 2024 and none in early June 2024. Resident #43 expressed dissatisfaction with the infrequency of baths, preferring bed baths due to discomfort with the shower chair. There was no documentation of refusal, and staff interviews revealed inconsistencies in the provision of scheduled baths. Interviews with staff, including CNAs and an LVN, highlighted a lack of adherence to the bathing schedule and inadequate documentation of refusals. The ADON and Administrator acknowledged the issue, attributing it to potential documentation errors and problems with the electronic charting system. Despite the lack of documented refusals, both residents reported not receiving their scheduled baths, which could lead to dignity issues and skin problems.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of proper signage and adherence to Enhanced Barrier Precautions for two residents. Resident #34, who had a urinary catheter, did not have a sign on her door indicating the need for Enhanced Barrier Precautions, which are necessary to prevent the spread of infection. The Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, acknowledged the absence of the sign and stated it should have been there. Similarly, Resident #203, who had a stage 4 pressure ulcer, a urinary catheter, and a gallbladder drain, also lacked proper signage on his door. During observations, it was noted that staff members, including CNA E, LVN G, and RN F, did not wear gowns while providing care to Resident #203, despite the requirement to do so under Enhanced Barrier Precautions. The ADON confirmed that Enhanced Barrier Precautions were in place for residents with urinary catheters and wounds to prevent infection spread. Interviews with staff revealed a lack of understanding and inconsistent application of Enhanced Barrier Precautions. CNA E and LVN G admitted to not wearing gowns during care activities, and CNA E was unaware of what Enhanced Barrier Precautions entailed. The facility's policy required the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms, but this was not consistently followed, leading to potential risks of cross-contamination and infection spread.
Inaccurate Resident Assessment Leads to Incorrect Diagnosis
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident, leading to an incorrect diagnosis of bipolar disorder. The resident, a female with Huntington's disease, mood disorder, and cognitive communication disorder, was inaccurately documented as having bipolar disorder on the Minimum Data Set (MDS). The MDS nurse, responsible for the accuracy of the MDS, acknowledged the absence of a bipolar diagnosis in the resident's chart and planned to correct the error with the assistance of the Regional Nurse. The inaccurate assessment could potentially impact the resident's treatment and care. Interviews with facility staff, including the MDS nurse, Assistant Director of Nursing (ADON), and Administrator (ADM), highlighted the importance of accurate assessments for proper resident care. The ADON emphasized that incorrect diagnoses could lead to inappropriate interventions and care plans. The facility's policy on MDS assessment data accuracy, aligned with federal regulations, mandates that assessments accurately reflect the resident's status through direct observation and communication with staff. The policy requires staff to certify the accuracy of their assessment portions, underscoring the significance of precise documentation.
Failure to Implement Comprehensive Care Plan for PASRR Positive Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #12, who was readmitted with multiple medical conditions including traumatic hemorrhage of the cerebrum, cognitive communication deficit, vascular dementia, and severe protein-calorie malnutrition. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on two or more staff for activities of daily living (ADLs). Despite these needs, the facility did not create a care plan that addressed the resident's PASRR (Preadmission Screening and Resident Review) positive status, which required specialized occupational therapy, physical therapy, and durable medical equipment. Interviews with facility staff, including the social worker, LVN, MDS nurse, ADON, and ADM, revealed a lack of clarity and responsibility in ensuring that the resident's PASRR positive status was included in the care plan. The MDS nurse was identified as responsible for completing the PASRR and ensuring it was reflected in the care plan, but this was not done. The facility's policy on comprehensive care planning emphasized the need for a person-centered care plan with measurable objectives and timeframes, but this was not adhered to for Resident #12, potentially impacting the resident's quality of life and access to necessary services.
Failure to Maintain Clean Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with COPD, heart failure, and other conditions. The resident's oxygen concentrator filter was observed to be covered in gray fuzz and dust-like particles, despite documentation indicating that the filter had been checked for cleanliness on multiple occasions. Interviews with staff revealed that the responsibility for cleaning the oxygen concentrator filters fell on the weekend night shift nurses, but the filter remained dirty over several days. Staff members, including an RN, an LVN, the ADON, and the ADM, acknowledged that a dirty oxygen concentrator filter could lead to allergens, reduced oxygen intake, and potential respiratory issues for the resident. The facility's policy on breathing therapy devices emphasized maintaining optimal breathing patterns and preventing infections, yet the observed condition of the oxygen concentrator filter contradicted these goals. The deficiency was identified through observations and interviews, highlighting a lapse in the facility's adherence to its own policies and procedures regarding respiratory care.
Improper Storage of Lantiseptic Cream
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls, and only authorized personnel had access to the keys. This deficiency was observed in the case of a resident who had a container of Lantiseptic skin protectant 50% cream on her bedside table. The cream was not stored in accordance with professional standards, as it was not locked away, and there was no order for its use in the resident's medication or treatment administration records. The resident involved was an elderly female with a history of dementia, atherosclerosis with gangrene, hypertensive heart disease, and a chronic ulcer. Her care plan included enhanced barrier precautions and the application of a moisture barrier after incontinence episodes. However, the Lantiseptic cream, which was supposed to be applied after such episodes, was not documented in her treatment records, and there was no order for its use. The cream was reportedly brought back by the resident from a hospital stay, and staff interviews revealed confusion about whether it was considered a medication and how it should be stored. Interviews with facility staff, including CNAs, LVNs, and the ADON, highlighted inconsistencies in the understanding and implementation of medication storage policies. Some staff considered Lantiseptic a medication that should be stored in a medication cart, while others did not. The facility's policy allowed for bedside storage of certain medications under specific conditions, but these conditions were not met in this case. The lack of clarity and adherence to storage protocols could potentially lead to misuse or harm, especially given the cognitive impairments of some residents.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, leading to deficiencies in addressing the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not include an intervention for a fall mat in the care plan, despite the resident being at risk for falls. Additionally, the facility did not develop a hospice care plan for the resident, even though hospice services had been initiated. These omissions were identified through record reviews and staff interviews, which revealed inconsistencies and delays in updating the care plan to reflect the resident's current needs and conditions. The resident in question was an elderly female with multiple diagnoses, including encephalopathy, intracerebral hemorrhage, brain tumor, protein-calorie malnutrition, diabetes with hyperglycemia, osteoporosis, and muscle weakness. Her cognitive function was severely impaired, requiring extensive assistance for transfers and bed mobility. Despite these conditions, the care plan did not adequately address fall risks or hospice care needs. The resident had a fall that resulted in her hitting her head on a bedside table, leading to a brain bleed, which further highlighted the inadequacies in her care plan. Interviews with various staff members, including an LVN, the MDS nurse, the DON, and the ADM, revealed a lack of clarity and communication regarding the resident's care plan updates. The MDS nurse mentioned that care plans should be updated within 24 hours of any significant change, but this was not done in the resident's case. The DON and ADM were unsure about the resident's fall risk status and whether hospice care had been properly care planned. The facility's policy on comprehensive care planning was not followed, resulting in the resident's needs not being fully met.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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