Highland Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 5819 Pecan Valley Dr, San Antonio, Texas 78223
- CMS Provider Number
- 45E341
- Inspections on file
- 26
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Highland Nursing Center during CMS and state inspections, most recent first.
Infection Prevention and Surveillance Program Not Established: The facility failed to maintain an infection prevention and control program with a system for surveillance of infections and communicable diseases. Infection tracking consisted of pharmacy worksheets and an anti-infective utilization report listing antibiotics, resident names, and prescribers, but not infection reasons, infection types, or infection rates. The CRN, who served as the Infection Preventionist, said she did not use a specific tracking method and relied on the antibiotic report and her knowledge of residents’ histories, while the DON said QAPI reviewed residents with active infections but not overall infection rates, trends, or surveillance data.
Staff COVID-19 Vaccination Not Offered or Documented: The facility failed to ensure staff were offered the 2025-2026 COVID-19 vaccine and did not provide records of staff acceptance or declination. Interviews showed the CRN and an RN stated the facility does not provide the vaccine to staff, and staff instead obtained it privately or through the contracted pharmacy using their own insurance or payment. The facility's Staff Vaccination policy did not include COVID-19 guidance.
Discharge planning was not developed or implemented for four residents. One resident with bipolar disorder and dementia had an attempted transfer, but the family said care plan meetings did not address discharge goals and requested records were not provided to the receiving facility. Three other residents, including cognitively intact residents with psychiatric, cardiac, mobility, and other diagnoses, had care plan conferences and care plans that did not include discharge planning; the DON confirmed no discharge care plans were in place, and the LSW said discharge goals were not routinely reviewed.
A resident with intact cognition, weakness, impaired mobility, and fall risk had 3 razors, rubbing alcohol, and mouth wash in his room, and he kept wine in a locked cabinet after buying it from a store. The A hall shower room was also found open with an unlocked cabinet containing razors. Staff stated the items were safety hazards, and the facility policy said razors were to be stored in secure locations so residents could not access them.
Kitchen food safety requirements were not followed when the ice machine was observed with black specks on the shaft, and a Maintenance Assistant with a short beard was observed in the kitchen without a beard guard. The Maintenance Assistant confirmed he was not wearing a beard guard and said he forgot, while the FSM and ADM stated staff in the kitchen needed hair restraints and the ice machine needed to be maintained to avoid contamination.
Incomplete resident medical records and missing provider progress notes. Surveyors found that multiple residents' charts lacked admission H&Ps and/or PCP progress notes, and some available notes were unsigned draft documents. The DON said provider notes were emailed to the Admin. for printing and filing, while the Admin. said he requested the records from the provider group but did not follow up further. The CRN stated she was unaware the documentation had to be maintained in the charts.
Rusted Kitchen Microwave Not Maintained in Safe Condition: A kitchen microwave was observed with a rusted spot in the corner exposing the inner area of the unit. The FSM, who was covering for the permanent FSM, stated she did not know the microwave was rusted, was unsure how long it had been that way, and confirmed the issue could make residents sick. The ADM stated he was not aware of the condition, and the facility policy required kitchen-essential equipment to be maintained in good repair.
A resident with depressive disorder, DM II, anxiety, bipolar disorder, impaired vision, and dependence for personal hygiene was observed with upper lip and chin hair while sitting in a wheelchair in the dining room. She said she was unaware of the facial hair and wanted staff to help her notice and address it. An LVN later confirmed the facial hair and said a CNA would take care of it, while staff and admin stated grooming and facial hair assistance were part of nursing/aide responsibilities and the facility grooming policy called for daily grooming.
Failure to include POA in care planning: A resident with bipolar disorder and dementia, and a BIMS score indicating severe cognitive impairment, was not shown to have his family member/POA included in care plan meetings or the formulation of his person-centered plan of care. The family member stated she was the legal POA for medical and financial decisions and had not been invited to any care plan meeting since admission, while the DON said family members were not routinely invited to participate in care plan meetings.
Failure to Report Alleged Financial Exploitation: A resident with bipolar disorder and dementia had a BIMS score indicating severe cognitive impairment. His POA alleged that the admin removed about $500 from the resident’s bank account after being added as a second POA, and the POA believed the act was theft. The DON was aware of the allegation, and the admin admitted taking the money but did not report the allegation to the SSA because he believed it was false.
Failure to Investigate and Report Alleged Exploitation: The facility did not thoroughly investigate or report an allegation that the Admin. was stealing money from a resident with bipolar disorder and dementia, whose BIMS score indicated severely impaired cognition. The resident’s family member said the Admin. admitted taking the money for business expenses, while the DON was unaware of any further investigation and the Admin., who served as the Abuse and Neglect Coordinator, said he did not report or investigate the allegation because he believed it was false.
Failure to include residents and families in care plan meetings. Two residents with documented care needs had care plans developed without documented resident or family signatures, and one resident stated she was not invited to meetings. The DON said she coordinated care plan meetings but did not routinely invite family members, and the LSW said she did not routinely attend care plan meetings.
Failure to provide routine dental services for a resident with bipolar disorder and dementia. The resident had severely impaired cognition, no documented routine or emergency dental provider care in the chart, and prior records showed dental pain, hot/cold sensitivity, and tooth pain. During observation, the resident had multiple missing teeth and brown discoloration to remaining teeth. The DON/Administrator stated the resident had not received dental care since 2024 because he had not complained of new issues and the facility had not pursued another dental provider.
Improper Dumpster Disposal and Maintenance: The facility failed to keep 1 dumpster properly secured and maintained. The dumpster had no plug in the bottom drain and the side door was partially open during observation. The FSM stated she was unaware the dumpster needed a plug and did not know who opened the side door, while the ADM stated the door should be closed and the dumpster should have a plug to prevent rodents.
The facility failed to provide adequate lighting and eliminate trip hazards in shower rooms, posing potential risks to residents. The B Hall shower lacked a light fixture, and the A Hall shower had a non-functioning bulb. Both showers had inclined ramps, with the A Hall ramp featuring a tiled bump that staff found challenging to navigate, potentially causing trips. Staff acknowledged these issues, and the DON and Administrator agreed on the need for corrective measures.
A resident had an unsigned consent for Thorazine, which was not prescribed, and the MAR lacked documentation. Another resident's care plan did not include an ordered abdominal binder, and a half side rail was inappropriately used for positioning.
A facility experienced a 55.56% medication error rate due to improper administration techniques. An LVN administered medications via g-tubes incorrectly by mixing them together instead of separately with water flushes. Additionally, a medication aide failed to administer prescribed medications to two residents due to misinterpretation of blood pressure parameters. These actions placed residents at risk of not receiving therapeutic effects and potential adverse reactions.
A LTC facility failed to maintain an effective infection prevention and control program. Staff did not adhere to standard precautions, such as changing gloves with hand hygiene between tasks and doffing PPE before exiting resident rooms. Additionally, oxygen concentrators were improperly stored in a public bathroom. These actions could lead to cross-contamination and increased infection risk.
Poor lighting and non-functional heaters were reported in shower rooms, with a resident expressing the need for improvements. A gap in the laundry door and improper placement of a shower curtain between dirty and clean areas were also noted. Additionally, a bump on a ramp and lack of lighting in the shower contributed to the deficiencies.
A resident with severe cognitive impairment and a history of pulling out her feeding tube did not have a comprehensive care plan that included the use of an abdominal binder, as ordered by the physician. Observations revealed the resident without the binder on multiple occasions, and staff interviews confirmed the oversight. The facility's DON acknowledged the risk of trauma or injury if the feeding tube was pulled out.
A deficiency was identified involving the inappropriate use of a 1/2 side rail for positioning a resident, which was not necessary for their needs. Additionally, an abdominal binder was ordered but not included in the resident's care plan. The facility failed to assess safety risks, review risks and benefits with the resident or representative, obtain informed consent, and ensure proper installation and maintenance of the bed rail.
A medication cart was left unsupervised and unsecured for 25 minutes in a hallway, allowing residents and staff to pass by freely. The cart was not assigned to the nurse who secured it, but to a medication aide on break. The DON and Administrator confirmed that carts should be secured when not in use.
The facility did not respect the guardian's request for two residents with dementia to be evaluated by a specific hospice company, instead defaulting to another company without consent. This action violated the residents' rights to make choices regarding their care.
Infection Prevention and Surveillance Program Not Established
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Record review showed the facility’s infection surveillance documentation consisted of 10 worksheets from the facility pharmacy that listed resident symptoms requiring antibiotic treatment and the antibiotic prescribed. An e-mail from the Admin. stated those 10 worksheets were the entirety of the infection surveillance documentation maintained by the facility. Record review of the facility’s anti-infective utilization report for February 2026 showed an undated pharmacy-generated summary of antibiotic treatments prescribed for residents, including resident names, medication names, administration directions, and prescribers. The report did not include the reason for antibiotics, type of infection, or infection rates. The CRN, who served as the Infection Preventionist, stated she did not use a specific method to track infections and relied on the antibiotic usage report to monitor infections, deducing the type of infection from the antibiotic prescribed and mentally calculating infection rates based on census. She was unsure how she used the report to monitor overall infection rates over extended time periods and was unsure of the overall infection rates or any trends since the prior survey. The DON stated the QAPI team reviewed residents with active infections but did not discuss overall infection rates, trends, or other surveillance data, and said the CRN managed infection surveillance. Requested infection control and infection surveillance policies were not provided prior to survey exit.
Staff COVID-19 Vaccination Not Offered or Documented
Penalty
Summary
The facility failed to implement policies and procedures to ensure each staff member was offered the COVID-19 vaccine for 1 of 1 facility reviewed for infection prevention. Surveyors requested records by e-mail for evidence of staff acceptance or declination of the 2025-2026 COVID-19 vaccination, but the facility did not provide those records before survey exit. The facility policy titled Staff Vaccination, dated 2003 and revised in March 2003, did not include guidance or policy related to COVID-19 vaccinations. During interviews, the CRN stated the facility does not offer COVID-19 vaccinations to staff and that staff may use the contracted pharmacy services provided to residents only if they provide payment or insurance information. She said most staff obtained vaccinations privately outside the facility and was unsure whether the facility maintained annual vaccination records for staff. RN A stated the facility does not provide COVID-19 vaccinations to staff and that she received her annual vaccinations at a local pharmacy without facility assistance. In a later interview, the CRN stated she believed the facility met the requirement because staff could obtain the vaccine through the facility pharmacy using their own health insurance, but she was unsure how staff without insurance coverage or the ability to pay would obtain the vaccination.
Discharge Planning Not Included in Care Plans
Penalty
Summary
The facility failed to ensure an effective discharge planning process that focused on residents’ discharge goals for 4 of 4 residents reviewed. Resident #3 was admitted with bipolar disorder and dementia and had a quarterly MDS showing a BIMS score of 06, indicating severely impaired cognitive status. During an attempted transfer in December 2025, the interdisciplinary care conference did not show discharge planning, and the resident’s family member reported she had not been invited to care plan meetings or discussed discharge planning with facility staff. She said she tried to transfer him to another nursing facility, but the receiving facility requested records that were never provided, and the resident was not accepted. For Resident #3, the record included an authorization signed by the family member for release of medical records to the proposed facility, but the facility did not provide evidence of documented discharge planning before survey exit. The family member reported that staff told her they were not aware of the records request, and she said the Administrator discouraged the transfer by discussing increased costs. The LSW said she did not review discharge or transfer goals with the resident or family and was not aware of the transfer request. The DON said the family member had not been invited to care plan meetings and was unaware of any discharge or transfer goals for the resident. The Administrator said records requests with a large volume of copies could have a fee and stated the records were not sent because the family member did not pay the fee. Resident #16, Resident #2, and Resident #1 each had care plan conferences and care plans that did not include discharge planning. Resident #16 was cognitively intact with a BIMS of 15/15 and had diagnoses including elevated myocardia, weakness, vitamin D deficiency, and reduced mobility. Resident #2 had diagnoses including depressive disorder, diabetes II, anxiety, and bipolar disorder and also had a BIMS of 15/15. Resident #1 had diagnoses including anxiety, schizophrenia, and depressive disorder and had a BIMS of 15/15. The DON stated there was no discharge care plan for Residents #16, #2, and #1, and the LSW said she did not routinely attend care plan meetings and did not review discharge or transfer goals unless staff requested it.
Unsafe Access to Razors and Alcohol
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards for Resident #16 and for the A hall shower room. Resident #16’s admission record showed diagnoses including elevated myocardia, weakness, vitamin D deficiency, and reduced mobility. His quarterly MDS showed a BIMS score of 15/15, and his care plan identified him as a fall risk with an unsteady gait, weakness, impaired mobility, and improved vision related to cataract surgery. During observation in his room, 3 razors, a 16-ounce bottle of rubbing alcohol, and 2 containers of mouth wash were found at the sink or in the medicine cabinet. Resident #16 stated he shaved himself in the room, kept razors there for that purpose, and bought alcohol and wine from the store, which he kept in a locked cabinet in his room. The A hall shower room was also observed with the door open and the cabinet unlocked, with 1 razor in the locked cabinet and 2 razors in the medicine cabinet. Staff interviews showed the charge nurse was not aware Resident #16 had razors, rubbing alcohol, and mouth wash in his room, and stated these were safety hazards. Other staff stated the shower room cabinet should be locked and razors kept at the nurse’s station, while the shower room should be closed and the cabinet containing razors should be locked. The facility policy stated razors in resident rooms and showers were to be documented and stored in secure locations so residents would not be able to access them.
Kitchen Food Safety and Hair Restraint Deficiencies
Penalty
Summary
Food safety requirements were not followed in the kitchen when the ice machine was observed with black specks on the ice machine shaft during initial rounds with the FSM. The observation was made in the kitchen area where food and ice are prepared and served, and the FSM later stated the black specks may have been dirt and that residents could get sick. The ADM also stated the ice machine needed to be kept maintained because it could contaminate the ice and cause residents to have stomach issues. The facility also failed to ensure a Maintenance Assistant with a short beard wore a beard guard while in the kitchen. On one observation, the Maintenance Assistant was near the microwave area without a beard guard, and on a later observation he was again in the kitchen without one. During interview, the Maintenance Assistant confirmed he was not wearing a beard guard and stated he forgot and was only in the kitchen for a short time. The Maintenance Supervisor later told him to wear a hairnet, and the FSM confirmed staff in the kitchen needed to have a hair restraint and that staff not wearing a hairnet or beard guard could affect residents by hair going into the food.
Incomplete resident medical records and missing provider progress notes
Penalty
Summary
The facility failed to ensure that medical records for 7 of 7 residents reviewed contained complete physician and other licensed professional progress notes. Residents #7, #5, #3, #22, #29, #30, and #33 all had paper charts that were missing admission histories and physicals or subsequent provider progress notes, or contained notes that were not signed and were marked as draft. The residents reviewed had diagnoses including dementia, hypertension, schizoaffective disorder, cerebral palsy, and schizophrenia. Record review showed Resident #7 and Resident #33 did not have an admission history and physical or any progress notes from later primary care provider visits in their charts. Resident #5 and Resident #30 had documentation of a most recent history and physical, but no additional provider evaluations were present after that date. Resident #3, Resident #22, and Resident #29 had a history and physical dated 4/22/2025 in the chart, but the document was watermarked draft and stated that it had not been signed. During interviews, the DON stated that provider progress notes were sent by email to the Admin., who printed them for filing in resident charts, and that she had previously requested access to the documentation to keep charts accurate and current. The Admin. said he had requested the documentation from the provider group in January 2026 but had not followed up further when no response was received. The CRN stated that maintaining admission histories, physicals, and provider progress notes was her responsibility along with the DON's, but she was unaware the documentation was required to be maintained in the charts and said the notes were not useful because they were based on nursing reports.
Rusted Kitchen Microwave Not Maintained in Safe Condition
Penalty
Summary
The facility failed to maintain kitchen essential equipment in safe operating condition when the microwave in the kitchen was observed with a rusted spot in the corner that exposed the inner area of the microwave. During the observation on 3/24/2026 at 10:00 AM, the FSM confirmed the microwave in the corner was rusted and exposing the inner area. On 3/25/2026 at 3:03 PM, the FSM stated she was new to the position and covering for the permanent FSM, did not know the microwave was rusted inside, and was not sure how long it had been in that condition. The FSM also stated the effect would be that it could make residents sick. At 5:23 PM the ADM stated he was not aware the kitchen microwave was rusted inside. Record review showed the facility policy, Kitchen Essential Equipment, required all kitchen-essential equipment to be maintained in good repair.
Failure to Maintain Resident Grooming and Dignity
Penalty
Summary
The facility failed to ensure Resident #2 was treated with respect and dignity by not addressing facial hair on her upper lip and chin area. Resident #2 was admitted and readmitted with diagnoses including depressive disorder, diabetes II, anxiety, and bipolar disorder. Her MDS summary indicated short-term and long-term memory issues, dependent personal hygiene, impaired vision, and verbal communication, while a later quarterly MDS showed a BIMS score of 15/15, impairment on one side of the upper extremity and both lower extremities, use of an electric wheelchair, and dependence for personal hygiene. Her care plan noted extensive assistance with self-care, a communication deficit, and poor vision. During observation, Resident #2 was seen sitting in her electric wheelchair in the dining room with upper lip and chin hairs. She stated she was not aware of the facial hair and would like staff to help and make her aware of it next time. A later observation again showed facial hair on her upper lip and chin, and LVN F confirmed it, stating she was not aware and would let a CNA take care of it. Interviews with staff and administration indicated that nursing staff or aides were responsible for grooming residents and offering assistance with facial hair, and the facility policy stated residents would be groomed daily, including shaving face/body hair for those who do not want it.
Failure to Include POA in Care Planning
Penalty
Summary
The facility failed to ensure that Resident #3 and his family member/POA were included in the development and implementation of his person-centered plan of care. Resident #3 was a male admitted on 3/02/2022 with diagnoses including bipolar disorder and dementia. His quarterly MDS reflected a BIMS score of 06, indicating severely impaired cognitive status. Record review of the quarterly care conference dated 12/12/2025 showed signatures from the DON, LSW, Activity Director, and one illegible signature, but the care plan did not show any discussion of Resident #3's capacity to make decisions or involvement of his family in the care planning process. During interview, Resident #3 declined to participate. His family member stated that she was his legal POA for medical and financial decisions, that he had mental health issues that prevented him from caring for himself or making decisions, and that she had not been invited to a care plan meeting since his admission to the facility. She said she contacted the facility or spoke with a nurse when she had questions, but found the process frustrating because it was difficult to get answers. The DON stated she coordinated care plan meetings and did not routinely invite family members to attend or participate in the formulation of the care plan, and said she would call family members by telephone if she had questions about a resident's care.
Failure to Report Alleged Financial Exploitation
Penalty
Summary
The facility failed to ensure that an allegation of exploitation involving a resident’s finances was reported to the State Survey Agency within the required timeframe. The resident was a male admitted in 2022 with diagnoses including bipolar disorder and dementia, and his quarterly MDS reflected a BIMS score of 06, indicating severely impaired cognitive status. His family member, who stated she was the legal POA for financial and medical issues, reported that in the fall of 2025 approximately $500 was removed from the resident’s bank account. She said the bank told her the administrator had been added as a second POA and that the money was withdrawn by the administrator, which she believed was suspicious because the resident only went to the bank when she took him. The family member said she confronted the administrator and DON about the withdrawal and was not given a clear explanation for why the money was taken or what it was used for. She told them she believed the act was theft and later reported her concerns to the State Attorney General’s office. The DON stated she was present when the allegation was made and was unsure why the administrator had taken money from the resident’s account or why the allegation was not reported to the SSA. The administrator acknowledged removing $500 from the account in October 2025, said he had been added as a POA to assist with the resident’s finances after a lapse in Medicaid coverage, and stated he did not report the allegation because he believed it was false.
Failure to Investigate and Report Alleged Exploitation
Penalty
Summary
The facility failed to ensure that an alleged violation of abuse, neglect, and exploitation involving Resident #3 was thoroughly investigated and reported to the SSA within five working days. Resident #3 was a male admitted to the facility with diagnoses including bipolar disorder and dementia, and his quarterly MDS reflected a BIMS score of 06, indicating severely impaired cognitive status. During record review, there was no evidence that the facility completed an investigation into the allegation that the Admin. was stealing money from Resident #3's bank account. Resident #3's family member reported that she confronted the Admin. about concerns that he was taking money from Resident #3's bank account, and she stated that he admitted taking the money and said it was for business expenses. The DON stated she was present during the allegation and was unsure why the Admin. did not report it to the SSA, and she was not aware of any further investigation. The Admin., who was also the Abuse and Neglect Coordinator, stated he did not report the allegation because he believed it was false and did not conduct an investigation because he already knew the allegation was untrue. The facility policy stated that all alleged violations must be thoroughly investigated and that evidence of such investigation must be maintained.
Failure to Include Residents and Families in Care Plan Meetings
Penalty
Summary
Comprehensive care plans were not developed with resident and representative participation to the extent practicable for 2 of 8 residents reviewed. Resident #2 was admitted with diagnoses including depressive disorder, diabetes II, anxiety, and bipolar disorder. Her records showed a BIMS score of 15/15, use of an electric wheelchair, impaired vision, dependence with personal hygiene, and care plan needs including extensive assistance with self-care, communication deficit, and poor vision. The care plan conference sheet did not document resident or staff signatures, and Resident #2 stated in interview that she had not been invited to care plan meetings. Resident #16’s record showed admission with diagnoses including elevated myocardia, weakness, vitamin D deficiency, and reduced mobility. His quarterly MDS showed a BIMS score of 15/15 and no history of falls, while his care plan identified him as a fall risk with unsteady gait, weakness, impaired mobility, ability to transfer self, and improved vision related to cataract surgery. In interview, the LSW stated she did not routinely attend care plan meetings. The DON stated she coordinated care plan meetings but did not routinely invite family members to attend or participate in the formulation of the care plan, and would call family members by telephone if she had questions about a resident’s care.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for one resident who was reviewed for dental care. The resident was a male admitted in 2022 with diagnoses including bipolar disorder and dementia, and his quarterly MDS submitted in February 2026 showed a BIMS score of 06, indicating severely impaired cognitive status. Section L of the MDS, which addresses oral/dental status, was not assessed. Review of the resident’s paper chart did not show documentation from a dental provider for routine or emergency care. The record included an email from the facility’s contracted dental provider to the Administrator dated December 2023 requesting an evaluation for the resident due to dental pain, and a New Patient Registration and Consent form dated March 2024 documenting a non-life threatening urgent dental need of hot/cold sensitivity and tooth pain. During observation in March 2026, the resident was noted to have multiple missing teeth in the upper and lower jaws and brown discoloration to the remaining teeth. In interview, the Administrator stated the resident had not received dental care since 2024 because he had not complained of new dental issues, was not aware the facility was required to assist residents with obtaining routine dental care including those with Medicaid, and had not sought an alternative or additional dental provider.
Improper Dumpster Disposal and Maintenance
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 1 of 1 dumpsters observed. During observation with the FSM, the garbage dumpster had no plug in the bottom drain and the side door was open about 1/4 of the way. On a later observation, the dumpster still did not have a plug. The FSM stated she was not aware the dumpster had to have a plug and was not sure who opened the side door. The ADM stated the dumpster door should be closed and the garbage dumpster should have a plug to prevent rodents. Record review of the facility's Garbage Dumpster policy stated the dumpster will have a plug in the bottom drain at all times to prevent vermin from entering and liquid waste from escaping.
Inadequate Lighting and Trip Hazards in Shower Rooms
Penalty
Summary
The facility failed to ensure safe and adequate lighting in the shower rooms, as well as to eliminate trip hazards, which could potentially place residents at risk for injuries. Specifically, the B Hall shower stall lacked a light fixture, resulting in dim lighting conditions, while the A Hall shower stall had a non-functioning light bulb, leaving the area inadequately illuminated. Additionally, both shower stalls featured inclined ramps leading into them, with the A Hall shower ramp having a tiled bump at the top, which was intended to prevent water drainage issues but posed a potential trip hazard. Observations and interviews with staff, including the Maintenance Director and CNAs, confirmed these deficiencies. The Maintenance Director acknowledged the absence of a light fixture in the B Hall shower and the non-functioning bulb in the A Hall shower, as well as the presence of the tiled bump on the A Hall ramp. CNAs expressed concerns about the difficulty in maneuvering residents over the bump and the potential for trips and falls, especially for residents who used the showers independently. The DON and Administrator agreed that the lighting issues needed correction and that the safety and necessity of the tiled bump required review. A policy was requested but not provided to the survey team before their exit.
Medication and Care Plan Deficiencies
Penalty
Summary
Resident #33 was involved in a deficiency related to medication management. The consent for Thorazine was not signed, and the medication was incorrectly associated with the resident, as they were not prescribed Thorazine. Additionally, the medication administration record (MAR) did not reflect the use of Thorazine for this resident. Resident #6 experienced a deficiency concerning the care plan and safety equipment. An order for an abdominal binder was not included in the resident's care plan, and the use of a half side rail for positioning was deemed inappropriate for this resident's needs.
High Medication Error Rate Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 55.56% error rate during the survey. This was observed in the administration of medications to four residents, where multiple errors were identified. LVN D administered medications to Residents #6 and #30 via their gastronomy tubes without following professional standards. Instead of administering each medication separately with a water flush in between, LVN D mixed all medications together and administered them simultaneously, which is contrary to the prescribed method. Additionally, the medications were administered late, with Resident #6 receiving them 11 minutes late and Resident #30 receiving them 50 minutes late. Further deficiencies were noted with Medication Aide I, who failed to administer prescribed medications to Residents #7 and #22. Resident #7 did not receive Amlodipine as prescribed due to a misinterpretation of blood pressure parameters, despite the blood pressure reading being within the acceptable range for administration. Similarly, Resident #22 did not receive Hydrochlorothiazide as prescribed, as Medication Aide I withheld the medication based on a low blood pressure reading, despite there being no stipulations in the physician's order to withhold the medication under such conditions. These practices placed residents at risk of not receiving the therapeutic effects of their medications and potential adverse reactions. The facility's failure to adhere to proper medication administration protocols, particularly for residents with feeding tubes, and the misinterpretation of medication administration parameters contributed to the high medication error rate. The lack of a policy for g-tube medication administration and medication errors further exacerbated the situation, as staff did not have clear guidelines to follow, leading to inconsistent and improper medication administration techniques.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to standard and transmission-based precautions. On one occasion, two CNAs assisted a resident with incontinent care but did not change gloves with hand hygiene between glove changes after handling soiled linens and supplies. This improper practice continued as they provided clean linens and adult briefs with the same contaminated gloves, and exited the resident's room without performing hand hygiene. Additionally, an LVN was observed administering medications to two residents without following proper infection control protocols. The LVN failed to change gloves with hand hygiene after touching residents' clothing and furniture before administering medications. Furthermore, the LVN did not doff potentially contaminated PPE gowns before exiting the residents' rooms, wearing them in the hallway, which could lead to cross-contamination. The facility also improperly stored oxygen concentrator equipment in a public bathroom, which is not a clean environment. This practice was confirmed by staff interviews, revealing a lack of space as the reason for this storage decision. The Director of Nursing and the Administrator acknowledged the expectations for infection control, which were not met, as evidenced by the staff's failure to adhere to standard precautions and enhanced barrier precautions for residents with g-tubes.
Environmental Deficiencies in Shower Rooms and Facility Areas
Penalty
Summary
Poor lighting was observed in shower rooms A and B, with a resident noting the need for better lighting and warmth, as the heaters in these rooms were not functioning. Additionally, there was a gap in the laundry door, and a shower curtain was improperly placed between dirty and clean areas. A bump was also noted on a ramp, and there was no light in the shower, contributing to the deficiencies identified.
Failure to Implement Care Plan for Resident with Feeding Tube
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and a history of pulling out her feeding tube. The care plan did not include the necessary intervention of applying an abdominal binder, as ordered by the physician, to prevent the resident from pulling out the feeding tube. This omission was observed during multiple instances where the resident was found without the abdominal binder in place, despite having a physician's order for its use at all times. Interviews with facility staff, including CNAs and an LVN, confirmed that the resident had a tendency to pull out her feeding tube and that an abdominal binder was supposed to be used to prevent this behavior. However, the binder was not consistently applied, and the facility's Director of Nursing acknowledged the potential for trauma or injury if the feeding tube was pulled out. Additionally, the facility was unable to provide a policy on care plan development and implementation when requested.
Inappropriate Use of Bed Rail and Unplanned Abdominal Binder
Penalty
Summary
The deficiency involves the inappropriate use of a 1/2 side rail for positioning a resident, which was not deemed necessary for the resident's needs. Additionally, there was an order for an abdominal binder that was not identified in the resident's care plan. The facility failed to assess the resident for safety risks associated with the use of the bed rail, review these risks and benefits with the resident or their representative, obtain informed consent, and ensure the correct installation and maintenance of the bed rail.
Unsupervised Medication Cart Poses Risk
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and that only authorized personnel had access to the keys. This deficiency was observed when a medication cart was left unsupervised and unsecured for 25 minutes in the hallway near a resident's room. During this time, residents, housekeepers, and CNAs were able to walk freely past the unattended cart, which posed a risk of unauthorized access to medications. An observation and interview revealed that the medication cart was not assigned to the nurse who was alerted to the situation, but rather to a medication aide who was likely on a break. The Director of Nursing (DON) confirmed that all medication carts should be secured when not in use, and the Administrator agreed with this expectation. Despite a request for the facility's policy on medication cart security, it was not provided by the time of the survey exit.
Failure to Honor Guardian's Hospice Choice
Penalty
Summary
The facility failed to uphold the rights of two residents by not allowing their guardian to choose the hospice company for their evaluation. Both residents, who were diagnosed with dementia and had cognitive impairments, had a guardian who requested evaluations from Hospice Company C. However, the facility proceeded with evaluations from Hospice Company D without the guardian's consent. This action was contrary to the guardian's explicit request and the facility's policy that residents have the right to make their own choices regarding care and services. The clinical records and communications indicate that the guardian had requested Hospice Company C to assess the residents for hospice services, but Doctor B and the facility did not honor this request. Instead, Hospice Company D conducted the evaluations, and the residents were deemed ineligible for hospice services. Staff interviews revealed a lack of awareness or adherence to the guardian's choice, with one nurse stating that if a hospice company was not selected by the resident, Hospice Company D was used by default. This oversight in respecting the guardian's choice could potentially exclude the responsible party from being involved in the residents' medical care and treatment decisions.
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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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