Hidalgo Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Edinburg, Texas.
- Location
- 4503 S Sugar Rd, Edinburg, Texas 78539
- CMS Provider Number
- 676346
- Inspections on file
- 32
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Hidalgo Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with moderate dementia and severe cognitive impairment was started on Zyprexa after a MH NP changed her medication regimen, and physician orders documented its use for depression and later unspecified psychosis. Progress notes showed that the responsible party (RP) was informed of psychiatric recommendations and was later contacted multiple times regarding a pending consent form, and also requested discontinuation of Zyprexa while the consent remained unsigned. Despite this, the MAR showed that Zyprexa was administered on two occasions before any written consent was obtained, contrary to staff statements and facility policy requiring a signed antipsychotic consent from the resident or RP and the prescriber, and prior disclosure of risks, benefits, and alternatives.
A resident with moderate dementia and severe cognitive impairment, but no documented psychosis or behavioral symptoms, was started on Zyprexa (olanzapine) 10 mg at bedtime after a mental health NP changed her medication regimen. Physician orders listed varying indications for the antipsychotic, including depression, unspecified psychosis, anxiety, and bipolar disorder, despite the clinical record and MDS lacking corresponding documented diagnoses at the time. Nursing staff reported that they were responsible for entering and clarifying antipsychotic orders and recognized that inappropriate indications for dementia residents could constitute a chemical restraint. The DON could not locate documentation supporting a stated history of schizophrenia, and the facility’s own psychotropic drug policy required a specific, diagnosed, and documented condition for such medications, leading surveyors to find that the antipsychotic was used without an adequate indication.
Failure to Notify LTC Ombudsman of Resident Discharges: The facility failed to send discharge notices to the LTC Ombudsman for most resident discharges, sending only AMA discharges instead of all discharges. The SW said she was instructed by the Administrator to report only AMA cases and did not know all discharges had to be sent, while the ADON and Administrator also stated they were unaware of the requirement and that the facility did not follow its Transfer and Discharge policy.
Food service safety deficiencies were observed in the kitchen and dining area. Two dietary employees were not wearing beard restraints properly, scratched non-stick pans were hanging in the dishwash room, the cook prepared raw ground beef without gloves, and the can opener had a black substance on the working side. In the dining area, a CNA touched a resident’s glass, dessert cup, and peaches while serving food. Surveyors also observed uncovered dinner rolls on top of the oven and ceiling vents with black substance and condensation dripping to the floor.
A resident with an indwelling Foley catheter and severe cognitive impairment was observed with the catheter bag/tubing laying on the floor beside the bed. An LVN stated it should not touch the floor because it could pick up bacteria, and the ADON confirmed the catheter should be secured on the bed frame side and not on the floor; the facility procedure also stated the catheter must be properly secured.
A resident receiving O2 via nasal cannula was observed with the tubing touching the floor and no oxygen sign posted outside the room. The resident had acute respiratory failure with hypercapnia and HF, and staff confirmed the missing sign and the tubing issue during interview.
Loose Tablets Found in Medication Carts: The facility failed to keep meds in proper labeled packaging when five loose tablets were found in one med cart and eight loose tablets/capsules were found in another med cart among residents’ blister packs. An MA said she was responsible for one cart and cleaned it at the end of her shift, while the ADON stated the cart should be cleaned once per shift with no loose pills, expired items, or disorganized supplies; the facility policy also required med carts and supplies to be clean and orderly.
A resident with an indwelling Foley catheter and diagnoses including bladder dysfunction and HF was observed receiving incontinent and catheter care by two CNAs who used gloves but did not wear gowns as required for EBP. Both CNAs stated they forgot the gowns, and the ADON confirmed that EBP required gown and glove use for residents with catheters, feeding tubes, or wounds.
A resident with intact cognition and multiple comorbidities, including DM and bilateral below-knee amputations, kept his wallet and debit card in a safe in the business office. He routinely requested his debit card to buy snacks, handing it to the assistant business office manager (ABOM) to purchase items from an employee lounge vending machine. On one such occasion, the ABOM retained the card instead of returning it to the business office manager (BOM), and there was no system in place to verify the card’s return to the safe. When the BOM later attempted to collect the resident’s applied income, the transaction was declined, and a bank review revealed numerous unauthorized transactions totaling over $1,300. The resident denied authorizing these charges, and facility interviews and document review, including a receipt from a local vendor bearing the ABOM’s name and the resident’s card number, showed that the ABOM had used the resident’s debit card without consent, constituting misappropriation of the resident’s funds.
A resident with multiple respiratory diagnoses did not receive BIPAP therapy as ordered when the primary machine malfunctioned and the RT on duty was unaware of the backup device, resulting in the resident being placed on supplemental oxygen for the night despite facility protocols and staff training regarding backup equipment.
A resident with mobility issues and a history of falls required a mechanical lift for transfers, but this was not documented in the care plan. CNAs used the lift for safety, but the LVN and DON were unaware, leading to a discrepancy between care provided and documented. The facility's policy requires comprehensive care plans, but this was not met for the resident.
A facility failed to document a resident's assessment after a CNA reported redness on the resident's leg. The LVN assessed the resident for flu symptoms instead and did not document the findings or inform the oncoming nurse. The resident, with dementia and other health issues, was unable to communicate effectively. Despite staff training on documentation, the LVN cited being busy as the reason for the oversight.
A resident with dementia and hemiplegia was verbally abused by a CNA during a transfer attempt. The resident attempted to hit the CNA, who responded with inappropriate language. The incident was overheard by an LVN, who intervened and reported the event to the administration. The resident was assessed and found to have no injuries.
Antipsychotic Administered Without Prior Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for an antipsychotic medication prior to administration. A female resident with moderate dementia, anxiety, and depression, and a BIMS score of 02 indicating severe cognitive impairment, was admitted with no documented psychiatric or mood disorders, no indicators of psychosis, and no behavioral symptoms. Her care plan, however, included a focus on the use of the antipsychotic medication Zyprexa related to psychosis, initiated and revised in mid-April 2026. On 03/18/2026, a mental health nurse practitioner evaluated the resident and ordered discontinuation of Keppra, Buspar, and melatonin, and initiation of Zyprexa 10 mg at bedtime and Topamax 100 mg twice daily. Physician orders documented Zyprexa 10 mg at bedtime first for depression and then for unspecified psychosis. Progress notes indicated that the resident’s responsible party (RP) understood the psychiatric recommendations, and later notes documented calls to the RP regarding a pending signature for consent and that discontinuation of Zyprexa was requested by the RP while the consent signature was still pending. The MAR showed that Zyprexa 10 mg was administered on two evenings in early April without a signed consent from the RP. Interviews with nursing staff confirmed that facility practice and policy required a signed consent form from the resident or RP and the physician/NP before administering antipsychotic medications, and that verbal consent alone was not sufficient. Staff acknowledged that administering an antipsychotic without a signed consent could mean the RP or resident was not informed of side effects or other information about the medication. The DON confirmed that the resident received Zyprexa on two occasions without a consent form signed by the RP, despite the facility’s written policy stating that, prior to initiating or increasing psychotropic medications, the resident or representative must be informed of benefits, risks, alternatives, and have the opportunity to accept or decline, with documentation of this information in a format chosen by the facility.
Inadequate Indication for Antipsychotic Use Resulting in Chemical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to prevent the use of unnecessary psychotropic medications and chemical restraints for one resident. The resident was an elderly female with moderate dementia, anxiety, and depression, admitted with severe cognitive impairment as evidenced by a BIMS score of 02. Her MDS showed no psychiatric or mood disorders, no indicators of psychosis such as hallucinations or delusions, and no behavioral symptoms. She required extensive assistance with ADLs, including showers, toileting, and personal hygiene. Her routine medications included antidepressants, an antibiotic, hypoglycemics (including insulin), and anticonvulsants. The clinical record showed that on a specific date, a mental health NP evaluated the resident and issued new orders to discontinue Keppra, Buspar, and melatonin, and to start Zyprexa (olanzapine) 10 mg at bedtime and Topamax 100 mg twice daily. Progress notes documented that these orders were carried out and the responsible party was notified. Subsequent physician orders listed multiple and changing indications for Zyprexa 10 mg at bedtime, including depression, unspecified psychosis, anxiety, and bipolar disorder, despite the resident’s MDS and record lacking documented psychosis, mood disorder, or bipolar diagnosis at that time. The Zyprexa order also carried a black box warning for increased mortality in elderly patients with dementia-related psychosis, and the medication was administered on multiple days during the month per the MAR. Interviews with nursing staff and the DON revealed that nurses were responsible for entering NP or physician antipsychotic orders into the computer and were expected to clarify any unclear or inappropriate indications, particularly for residents with Alzheimer’s or dementia. LVNs interviewed acknowledged that antipsychotics for dementia residents required a specific, accurate indication and that vague indications such as altered mental status would be inappropriate, potentially constituting a chemical restraint. The DON stated that the NP had written the Zyprexa order for psychosis and later referenced a history of schizophrenia and bipolar disorder, but the DON could not locate documentation of schizophrenia in the record. The facility’s psychotropic drug use policy required that psychotropic medications only be used to treat a specific, diagnosed, and documented condition and not as a chemical restraint, and defined chemical restraint as any drug used for discipline or staff convenience and not required to treat medical symptoms. The lack of an adequate, documented indication for Zyprexa prior to its administration constituted the identified deficiency.
Failure to Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to send a copy of residents’ discharge notices, prior to discharge, to the representative of the Office of State Long-Term Care Ombudsman for 77 of 81 residents discharged during the first 3 months of 2026. Record review of the monthly discharge report dated 04/14/2026 showed that only 4 discharges, all Against Medical Advice (AMA), were sent to the LTC Ombudsman for January, February, and March 2026. The facility policy for Transfer and Discharge stated that the facility would maintain evidence that the notice was sent to the Ombudsman. During interview, the Social Worker stated she had been instructed by the Administrator to send only AMA discharges to the LTC Ombudsman and said she did not know she was supposed to send all resident discharges monthly or bi-monthly. The ADON stated she was not aware the Ombudsman was to receive notice of all discharges every month, and the Administrator stated the facility failed to follow its policy and procedure for notifying the LTC Ombudsman of monthly discharges. The Administrator also stated the Social Worker had not brought the failure to his attention and acknowledged that only AMA discharges had been reported for the first three months of 2026.
Food Service Safety and Infection Control Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen and dining area. During an initial kitchen tour, surveyors observed two male dietary employees not wearing beard restraints properly, a set of 11 non-stick pans with scratched or peeling coating hanging in the dishwash room, the cook preparing raw ground beef without gloves, and a can opener with a black substance coating the working side. The facility’s policies stated that food was to be prepared and handled according to state and US Food Codes and that beard coverings and other hair restraints must be worn. During a dining observation, CNA C was observed serving A resident and touching the rim of the drinking glass and dessert cups after removing protective covering, then touching the peaches with her finger as she placed the cup on the resident’s table. The resident had diagnoses including Alzheimer’s disease, dementia, contracture, and cognitive communication deficit, and was unable to answer surveyor questions during interview. The observation documented improper infection control during food service and direct contact with the resident’s food while serving it. In a later kitchen observation, two cookie sheets of dinner rolls were seen uncovered and sitting on top of the self-standing oven, and the oven doors were observed open while the rolls were being removed and not closed immediately afterward. Surveyors also observed 7 of 9 ceiling air conditioning vents with a black substance around the edges and condensation dripping onto the floor. Interviews with staff and management confirmed awareness of the beard restraint issue, scratched pans, can opener cleaning, uncovered rolls, glove use with raw meat, and the condensation around the vents, and the facility’s food storage policy required FIFO rotation and storage of food according to state, federal, and US Food Codes.
Improper Foley Catheter Placement
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling urinary catheter when the catheter tubing/bag was observed touching the floor. Resident #19 was a female admitted with a diagnosis of neuromuscular dysfunction of the bladder and had severe impaired cognition with a BIMS score of 1. Her care plan identified that she had a Foley catheter for neuromuscular dysfunction of the bladder, with the catheter bag and tubing to be kept below the level of the bladder and away from the entrance room door. The order summary also listed a Foley catheter with an 18 French, 30 milliliter balloon. During an observation, Resident #19's indwelling catheter bag was noted laying on the floor on the left side of her bed. When informed of this, an LVN stated the bag should not be touching the floor and explained that if it was on the floor it would not drain well and could pick up bacteria from the floor. The ADON later stated the catheter should be on the side of the bed, not on the moving part of the bed frame, so it would not fall, and confirmed it should not be touching the floor because residents could be at risk of infection. The facility's nursing procedure for indwelling urinary catheter care and removal stated to make sure the catheter is properly secured.
Oxygen tubing on floor and missing oxygen sign
Penalty
Summary
Resident #20, a [AGE]-year-old male admitted on 4/8/2026 with diagnoses including Acute Respiratory Failure with Hypercapnia and Heart Failure, was observed on 4/12/2026 lying in bed wearing a nasal cannula and receiving oxygen at 2 liters per minute. During that observation, the oxygen tubing was touching the floor without a protective sleeve, and there was no oxygen sign posted outside his room. His record showed he was on oxygen therapy while a resident, with a care plan noting oxygen therapy PRN for shortness of breath and physician orders started 4/12/2026 for oxygen at 2 liters per minute every shift for hypoxia. During interview, the LVN stated all staff were responsible for posting the oxygen sign outside residents' rooms and verified that Resident #20 did not have one posted. She also stated that oxygen tubing should not touch the floor because it could become contaminated and cause infection, and that the sign was important so people entering the facility would know oxygen was in use for safety. The ADON stated floor nurses were responsible for verifying the tubing was not touching the floor every shift because of infection risk, and said the admitting nurse was responsible for posting the oxygen sign, while also noting that the sign was important for everyone to know oxygen was in use in that room.
Loose Tablets Found in Medication Carts
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, including the appropriate accessory and cautionary instructions and expiration date when applicable. During observation of the 100/200 hall medication cart at 2:37 PM on 04/13/26, five assorted tablets were found loose in the second drawer from the top among blister packs of medications for residents on the 100 and 200 halls. During observation of the 300/400 hall medication cart at 2:54 PM on 04/13/26, eight assorted tablets were found loose in the second drawer from the top among blister packs of medications for residents on the 300 and 400 halls. In interview, MA A stated she was responsible for the 100/200 hall medication cart when the loose pills were found and said she always cleaned out her cart at the end of her shift, including looking for expired medications and loose tablets. MA A stated she had found loose tablets in her cart before when cleaning it and that keeping the cart clean and organized was important to help prevent contamination and protect residents' property. The ADON stated it was nursing best practice for the person responsible for the medication cart to ensure it was cleaned appropriately once per shift, with no loose pills, properly sealed liquids, no expired items, and a clean, organized cart. The facility policy titled Medication Carts and Supplies for Administering Meds, last revised 10/01/19, stated the licensed nurse or medication aide should maintain a clean top surface on the medication cart while passing medications and clean and replenish the medication cart after each use, and that equipment and supplies relating to medication administration are clean and orderly.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents reviewed for infection control. Resident #20 was a [AGE]-year-old male admitted on 4/8/2026 with diagnoses including neuromuscular dysfunction of the bladder and heart failure. His MDS assessment indicated he had an indwelling catheter, and his care plan identified a need for Enhanced Barrier Precautions due to the Foley catheter. During an incontinent care observation, CNA B and CNA C entered the resident’s room, performed hand hygiene, donned gloves, and prepared supplies. They later discarded the gloves, used hand sanitizer, and put on new gloves, but did not use gowns during incontinent care and catheter care. CNA B stated she should have worn a gown and had overlooked it, and CNA C stated she forgot to use the gown. The ADON stated EBP required staff to wear a gown and gloves for residents with a catheter, feeding tube, or wounds, and the facility’s policy stated EBP included targeted gown and glove use during high-contact resident care activities for residents with urinary catheters.
Failure to Safeguard Resident Debit Card Resulting in Misappropriation of Funds
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s personal funds and belongings, specifically the resident’s debit card, from misappropriation. The resident was a 58-year-old male with bilateral below-knee amputations, morbid obesity, diabetes, and a need for assistance with personal care. His quarterly MDS showed a BIMS score of 13, indicating intact cognition. The resident kept his wallet, containing his driver’s license, insurance cards, Social Security card, and debit card, in a safe in the Business Office Manager’s (BOM) office at his own request. He reported that he would request his wallet or debit card from the BOM when he needed to make purchases and that he had never allowed anyone to use his debit card or loaned money to staff. According to the resident, the last time he requested his debit card was in late November, when he wanted a cinnamon roll from a vending machine located in the employee lounge. The BOM gave him his debit card, and he then handed it to the Assistant Business Office Manager (ABOM) to purchase the snack. After receiving the cinnamon roll, the resident returned to his room while the ABOM retained possession of the debit card, telling him she would return it to the BOM. The resident stated that in early January, the BOM informed him that his bank account had been drained and that he had a negative balance, leaving him without funds to pay his applied income for that month. The resident questioned how this could have occurred if only the BOM and ABOM had access to his debit card and suspected the ABOM had used it without his permission. The BOM confirmed that the resident’s wallet was stored in a safe in her office and that the resident regularly requested his debit card to buy cinnamon rolls from the employee lounge vending machine, typically asking the ABOM to make the purchase. She recalled that at the end of November the resident requested his debit card and gave it to the ABOM, but she did not remember whether the ABOM returned the card. The BOM acknowledged that prior to December there was no system in place to ensure the resident’s debit card was returned to the safe, and she did not track the card’s return because she trusted the ABOM and was busy. In early January, when the BOM attempted to collect the resident’s applied income, the transaction was declined, prompting a review of the resident’s bank account. Bank records showed multiple unauthorized transactions in December totaling $1,340.16, and the resident disputed all but three of them. The facility’s internal investigation, including review of a receipt from a local oil change company bearing the ABOM’s name, her vehicle information, the amount charged, and the resident’s debit card number, led the Administrator to substantiate that the ABOM had used the resident’s debit card without consent, resulting in misappropriation of the resident’s funds.
Failure to Provide BIPAP as Ordered Due to Staff Unawareness of Backup Equipment
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care was provided with a BIPAP machine as ordered by the physician. The resident, a male with diagnoses including acute and chronic respiratory failure with hypercapnia, COPD, dependence on supplemental oxygen, obstructive sleep apnea, and pulmonary hypertension, had a physician's order for BIPAP use at night and as needed. On the night in question, the resident's BIPAP machine malfunctioned after being removed for medication administration, and the respiratory therapist (RT) on duty was unable to restore its function. Despite the existence of a backup BIPAP machine in the facility, the RT stated he was not aware of its availability until several hours later, by which time the resident was already asleep. The resident was placed on supplemental oxygen for the remainder of the night. Interviews with other staff, including another RT, a registered nurse, the DON, and the administrator, confirmed that a backup BIPAP machine was available and that staff had been in-serviced on its location and use. Documentation also indicated that the BIPAP machine and backup equipment were to be checked at the beginning and end of each shift, with a sign-off sheet for accountability. The resident did not experience any immediate negative outcomes during the incident, as his oxygen saturation levels remained stable and he did not exhibit shortness of breath. However, the failure to provide the BIPAP machine as ordered constituted a deficiency in following physician orders and ensuring respiratory care consistent with professional standards of practice. The facility's policy required notification and action in circumstances requiring alteration of treatment, such as equipment malfunction, but this was not followed in this instance.
Failure to Document Mechanical Lift Requirement in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #247, which did not reflect the need for a mechanical lift for transfers. The resident, a male with a history of intervertebral disc degeneration, muscle wasting, abnormalities of gait and mobility, and a history of falling, was admitted with a requirement for substantial assistance in transfers. Despite these needs, the care plan only indicated a two-person assist for transfers without specifying the use of a mechanical lift. Observations and interviews revealed that Certified Nursing Assistants (CNAs) were using a mechanical lift for the resident's transfers to ensure safety due to his size and uncoordinated movements. However, this practice was not documented in the care plan, and there was a lack of communication among staff regarding this requirement. The CNAs were aware of the need for a mechanical lift, but the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) were not informed, leading to a discrepancy between the care provided and the documented care plan. The facility's policy mandates the development of a comprehensive care plan that includes measurable objectives and timeframes to meet the resident's needs. However, the care plan for Resident #247 did not include the necessary details about the use of a mechanical lift, which could potentially place residents at risk of not receiving the appropriate care. Despite the oversight, the DON confirmed that the resident had not sustained any negative outcomes due to the care plan's omission.
Failure to Document Resident Assessment
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for a resident who was assessed for potential health concerns. Specifically, a Licensed Vocational Nurse (LVN) did not document an assessment after being informed by a Certified Nursing Assistant (CNA) about redness observed on a resident's leg. The resident, an elderly female with multiple diagnoses including unspecified dementia and rheumatoid arthritis, was unable to complete an interview due to cognitive impairments. Despite being alerted to the redness, the LVN assessed the resident for flu symptoms instead and failed to document any findings or communicate the concern to the oncoming nurse. Interviews with staff revealed that the CNA had clearly communicated the specific location of the redness to the LVN, who acknowledged the oversight in documentation due to being preoccupied with other residents. Subsequent assessments by other staff members did not note any redness or bruising, and the Director of Nursing confirmed that staff had been trained on proper documentation procedures. The facility's policy mandates accurate and timely documentation to reflect the resident's experiences and progress, which was not adhered to in this instance.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving a CNA and a resident. The resident, a male with a history of hemiplegia, dementia, and cognitive communication deficit, was involved in an altercation with CNA A. During the incident, the resident attempted to hit the CNA while being assisted to transfer to a wheelchair. In response, CNA A used obscene language in Spanish towards the resident, which was overheard by LVN B, who was nearby. The resident's medical records indicated that he had a potential for physical aggression due to dementia and poor impulse control. On the day of the incident, LVN B heard loud obscene yelling coming from the resident's room and intervened. The CNA was observed deflecting the resident's punches and using inappropriate language. The resident expressed that he did not want to go to the dining room but did not provide a reason for his aggression. After the incident, the resident was assessed and found to have no visible injuries or pain. Interviews and written statements from the staff involved confirmed the occurrence of verbal abuse. CNA A admitted to using inappropriate language during the altercation, citing a loss of temper as the reason. The facility's policy on abuse, neglect, and exploitation defines verbal abuse as the use of disparaging and derogatory terms towards residents. The incident was reported to the facility's administration, and the CNA was instructed to leave the facility immediately after the event.
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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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