Hilltop Park Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Weatherford, Texas.
- Location
- 970 Hilltop Dr, Weatherford, Texas 76086
- CMS Provider Number
- 675988
- Inspections on file
- 31
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Hilltop Park Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, vascular dementia, and prior stroke received quetiapine, including a dosage increase, without required written consent. Physician orders and the MAR showed the antipsychotic was initiated and then increased, but the EMR lacked HHSC Form 3713 and any signed consent from the resident or representative. A facility consent form for Seroquel had no signature, and a prior ADON documented only a verbal consent without evidence that side effects were explained or understood. In interviews, an LVN and the CCN confirmed that facility policy and state guidance require signed written consent, not verbal consent, before administering antipsychotic medications, and acknowledged that no valid consent or updated consent for the dosage change was on file.
A resident with Alzheimer’s disease, vascular dementia, and prior stroke was given Quetiapine (Seroquel) at bedtime, with the dose later increased, under an order written for “vascular dementia with agitation.” The MAR confirmed administration of the antipsychotic as ordered. The Interim DON and CCN acknowledged that this diagnosis was not appropriate to justify Quetiapine use and that it could cause oversedation in elderly residents. Facility policy limited antipsychotic use to specific psychiatric diagnoses such as schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, and psychosis, generally in the absence of dementia, and required use at the lowest effective dose for the shortest duration. The resident’s treatment did not conform to these policy criteria, resulting in a failure to ensure freedom from unnecessary chemical restraint.
A resident with Alzheimer’s disease, vascular dementia, acute cystitis, stroke history, severe cognitive impairment (BIMS 02), delusions, behavioral symptoms, incontinence, mobility limitations, and scheduled pain medication was admitted, but no baseline care plan was developed or implemented within 48 hours as required by facility policy. The EMR “Baseline Care Plan” form was not completed and was later found to have been deleted, with staff unable to explain who was responsible for completing or deleting it. The CCN and MDS nurse both acknowledged that this failure could put residents at risk for not receiving needed care.
A resident with a history of cerebral infarct and dysphagia experienced prolonged nausea, vomiting, and diarrhea without physician notification. The facility failed to inform the physician or family of the resident's deteriorating condition, leading to hospitalization for hypovolemic shock and sepsis. Staff interviews revealed a lack of awareness and action, resulting in an Immediate Jeopardy situation.
A resident with a history of cerebral infarct and dysphagia experienced nausea, vomiting, and diarrhea over eight days, but the facility failed to notify the physician or administer feedings as ordered. The resident was hospitalized for hypovolemic shock and sepsis. Staff were aware of the symptoms but did not communicate them, leading to a serious decline in health.
Two CNAs failed to follow proper hand hygiene protocols during incontinent care for two residents, leading to potential cross-contamination. One CNA did not wash or sanitize her hands before applying gloves and used the same gloves throughout the procedure. The other CNA did not change gloves or sanitize hands before handling a clean brief. Both CNAs had been trained and competency-checked, yet did not adhere to infection control policies, placing residents at risk for infection.
The facility failed to maintain food safety standards and equipment maintenance, with issues such as improperly stored utensils, soiled kitchen equipment, and inadequate dishwashing documentation. Additionally, the Memory Care Nourishment Room's refrigerator-freezer lacked a thermometer, and resident food was undated, posing risks to residents' health.
The facility failed to develop comprehensive care plans for two residents, one with complex mental health needs and another admitted to hospice care. The care plans lacked specific details on prescribed medications and hospice services, contrary to the facility's policy requiring measurable objectives and timetables to meet residents' needs.
A facility failed to coordinate a PASRR assessment for a resident with mental illness, including diagnoses of paranoid schizophrenia and bipolar disorder. The resident's PASRR Level One Screening Form did not reflect her mental illness, and necessary forms were not completed. Interviews revealed that MDS Coordinators were aware of the need for accurate documentation but failed to ensure completion. The Regional Clinical Reimbursement Specialist confirmed incorrect coding on the PL1 form, attributing the failure to previous MDS Nurses' lack of monitoring.
A facility failed to obtain informed consent for bed rail use for a resident with a history of falls and dementia. Despite the absence of consent and assessment, bed rails were installed, contrary to facility policy requiring assessments and informed consent. Interviews with staff confirmed the oversight, highlighting a lapse in following established procedures.
A resident with C-Diff was not properly protected due to a nurse's failure to wear PPE and use effective hand hygiene. The nurse admitted to forgetting to don the necessary gear and initially used hand sanitizer instead of soap and water, which is ineffective against C-Diff. Interviews with facility staff confirmed the expectation for proper PPE use and hand hygiene, highlighting a lapse in following infection control protocols.
The facility did not post the actual hours worked by RNs, LVNs, and CNAs responsible for resident care per shift. Observations on two days showed missing information on the daily nursing staffing postings. Interviews revealed that the DON was unaware of the requirement, and the ADON admitted to not including the actual hours worked. The Administrator acknowledged the oversight and mentioned plans to modify the form to comply with the policy.
A resident's Admission MDS assessment failed to accurately reflect her skin integrity issues, treatments, and lower extremity impairments. The inaccuracies were confirmed by the Wound Care Nurse and the DON, who acknowledged that the MDS nurse responsible was no longer employed and that corrections were being made.
A facility failed to develop and implement a baseline care plan within 48 hours for a resident admitted with sepsis, cellulitis, and an unstageable pressure wound. The DON acknowledged the oversight, which did not comply with the facility's policy, potentially putting the resident at risk for not receiving necessary care.
The facility failed to maintain accurate clinical records for a resident, including wound treatments, shower schedules, and bladder records. Interviews revealed that wound care was performed but not documented, and the shower schedule was inaccurately entered into the electronic system, leading to discrepancies.
The facility failed to ensure that daily nurse staffing information was posted at the beginning of each shift in a prominent place accessible to residents and visitors. The staffing information was outdated and kept in a binder book instead of being displayed as required by the facility's policy. Both the DON and ADON acknowledged the oversight, which could cause confusion regarding staffing and resident care issues.
Failure to Obtain Written Consent for Antipsychotic Medication and Dosage Increase
Penalty
Summary
The deficiency involves the facility’s failure to obtain proper written informed consent for the use and dosage increase of an antipsychotic medication for one resident. The resident was an elderly female with Alzheimer’s disease, vascular dementia, and a history of stroke, admitted with significant cognitive impairment as evidenced by a BIMS score of 00, indicating she was unable to complete the BIMS test. Her MDS reflected that she was receiving an antipsychotic medication. Physician orders showed quetiapine 50 mg at bedtime was initiated and later increased to two 50 mg tablets at bedtime, and the MAR confirmed that these doses were administered over several days. Record review of the resident’s electronic medical record revealed there was no HHSC Form 3713, Consent for Antipsychotic or Neuroleptic Medication Treatment, on file. A facility consent form for Seroquel lacked a resident or representative signature, and although a verbal consent was documented by a prior ADON for quetiapine 50 mg at bedtime, there was no evidence that side effects were discussed or that the representative acknowledged understanding them. There was also no documentation that the resident or her representative consented to or was aware of the increased dosage of quetiapine before it was administered. Interviews with staff confirmed that the facility’s process required obtaining signed consents, including HHSC Form 3713 and a psychotropic consent form, prior to administering antipsychotic medications. LVN A stated that medications could not be given until both consents were signed by the resident or representative. The CCN, interviewed with the Interim DON present, acknowledged that nurses were responsible for obtaining consents before administering psychoactive medications, that no consent for quetiapine or updated dosage could be found for this resident, and that the existing Seroquel consent form lacked a physical signature. The CCN also stated she was unaware that verbal consents were not appropriate for this medication and noted that changes in nursing administration and unfamiliarity with consent requirements may have contributed to the missing consent. Facility policy and an HHSC provider letter specified that written consent on Form 3713 must be obtained prior to the first dose, that verbal consent does not meet rule requirements, and that NF staff cannot sign on behalf of the resident.
Inappropriate Antipsychotic Use Without Proper Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from chemical restraints not required to treat medical symptoms, specifically through the use of the antipsychotic medication Quetiapine (Seroquel) without an appropriate diagnosis. A female resident with Alzheimer’s disease, vascular dementia, and a history of stroke was admitted with these conditions documented on her face sheet. Physician orders showed Quetiapine 50 mg at bedtime for “vascular dementia with agitation,” later increased to two 50 mg tablets at bedtime for the same indication. The MAR confirmed that the resident received Quetiapine 50 mg nightly over multiple days, including after the dose increase. During interviews, the Interim DON and the CCN both stated that “vascular dementia with agitation” was not an appropriate diagnosis to justify the use of Quetiapine and acknowledged that the medication could cause oversedation in elderly residents. The CCN reported that the Hospice nurse had obtained the order for Quetiapine. Review of the facility’s Antipsychotic Medication Use policy, revised March 2025, showed that antipsychotics were to be used only when necessary to treat specific indicated conditions, generally limited to diagnoses such as schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, psychosis, and in the absence of dementia, and that they should be prescribed at the lowest possible dose for the shortest period of time. The resident’s use of Quetiapine for vascular dementia with agitation did not align with these stated indications, resulting in the cited deficiency.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed that the resident, an older female with Alzheimer’s disease, vascular dementia, acute cystitis, and a history of stroke, was admitted on an identified date, but no baseline care plan was completed within 48 hours following admission. Her admission MDS documented a BIMS score of 02 indicating severe cognitive impairment, the presence of delusions and physical behavioral symptoms directed toward others, use of a walker with need for touch assistance and supervision to ambulate, partial to moderate assistance with transfers, bowel and bladder incontinence, and receipt of scheduled pain medication. Despite these identified needs, the baseline care plan form in the EMR was not completed as required. During interviews, the Clinical Care Nurse (CCN) stated that the EMR form titled “Baseline care plan” for this resident was not completed and that the prior DON had been responsible for delegating the task, but she was unsure who had been assigned to complete it. The MDS nurse reported that the “Baseline Care Plan” form in the EMR had been deleted and was not completed, and although her name appeared on the deleted form, she did not know who deleted it or why it was not completed. Both staff members acknowledged that this failure could put residents at risk for not getting needed care. Review of the facility’s policy titled “Care Plans – Baseline” dated November 14, 2023, confirmed that a baseline plan of care to meet the resident’s immediate needs must be developed within 48 hours of admission, and that the interdisciplinary team is to review practitioner orders and implement a baseline care plan including initial goals, physician and dietary orders, therapy and social services, and provide a copy to the resident or representative.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately inform a resident's physician and family member of a significant change in the resident's condition, which included nausea, vomiting, and diarrhea lasting over eight days. The resident, who had a history of cerebral infarct, dysphagia, and was dependent on a feeding tube, experienced these symptoms from December 22 to December 30 without improvement. Despite having orders for Zofran to manage nausea and vomiting, the facility did not notify the physician until December 30, when the resident's condition had severely deteriorated. During the period of illness, the resident's feeding tube was intermittently turned off, and the resident's condition was not properly assessed or communicated to the physician. The nursing staff, including several LVNs, failed to recognize the need for medical intervention and did not follow the facility's policy for notifying the physician of a significant change in condition. The resident was eventually transferred to the hospital, where she was diagnosed with hypovolemic shock, sepsis, and required emergency surgical intervention. Interviews with staff revealed a lack of awareness and action regarding the resident's deteriorating condition. The Director of Nursing and the Administrator were unaware of the situation until it was brought to their attention by surveyors. The facility's policy required prompt notification of the physician and family in the event of a significant change in a resident's condition, which was not adhered to in this case, leading to an Immediate Jeopardy situation.
Removal Plan
- Verbal policy review of Policy of Change of Condition or Status/SBAR change of condition was provided by the Corporate Quality Improvement Nurse to DON/ADON.
- In-services were initiated by the Director of Nursing/Quality Improvement Nurse to educate on notifying physicians immediately following detailed assessment with any resident change of condition to include the use of the SBAR/eInteract.
- Education/In-service was initiated to the DON, ADONs by the Corporate Quality Improvement Nurse on the morning clinical start-up process to ensure that any changes of condition would be addressed.
- The Stop and Watch early warning communication tool was initiated, training and education started to the certified nurses' aides utilizing the alert system.
- The SBAR/eInteract is being monitored in the clinical morning startup daily by DON/ADON/Designee.
- Oversight will be provided by the Administrator/DON/Designee.
- Notification protocol and SBAR understanding will be tested by giving a test to LVNs and RNs that cover SBAR education and notification of physician regarding change of condition.
- Change of condition will be reported from shift to shift up to nurse management by utilizing the SBAR/eInteract process and 24-hour report tool and reviewed daily in clinical start-up with oversight provided by DON/ADON/Designee.
- DON/ADON/Designee will be responsible for reviewing SBAR/24-hour report/nurse to nurse huddle and hand-off, daily at morning clinical start up.
- Discrepancies will be addressed immediately with root-cause analysis and brought to QAPI with the oversight with the Medical Director monthly for six months.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident who was reviewed for notification of change in condition. The resident, who had a history of cerebral infarct, dysphagia, and was dependent on a feeding tube, experienced nausea, vomiting, and diarrhea over a period of eight days. Despite these symptoms, the facility did not notify the resident's attending physician of the condition change, nor did they ensure the resident's feedings were administered as ordered by the physician. During the period from December 22 to December 30, the resident's condition deteriorated, leading to hospitalization for hypovolemic shock, sepsis, and a urinary tract infection. The facility's nursing staff failed to document or communicate the resident's ongoing symptoms and the holding of feedings to the physician. Interviews with staff revealed that multiple nurses were aware of the resident's symptoms but did not notify the physician, believing that the standing order for Zofran was sufficient. The facility's Director of Nursing and Administrator were unaware of the resident's condition change until it was brought to their attention by a surveyor. The facility's policy required prompt notification of the physician for any significant change in a resident's condition, which was not followed in this case. The lack of communication and failure to adhere to the care plan resulted in a serious decline in the resident's health, necessitating emergency medical intervention.
Removal Plan
- Verbal policy review of Policy of Change of Condition or Status/SBAR change of condition was provided by the Corporate Quality Improvement Nurse to DON/ADON.
- In-services were initiated by the Director of Nursing/Quality Improvement Nurse to educate on notifying physicians immediately following detailed assessment with any resident change of condition to include the use of the SBAR/eInteract.
- Education/In-service was initiated to the DON, ADONs by the Corporate Quality Improvement Nurse on the morning clinical start-up process to ensure that any changes of condition would be addressed.
- The Stop and Watch early warning communication tool was initiated, training and education started to the certified nurses' aides utilizing the alert system.
- The SBAR/eInteract is being monitored in the clinical morning startup by DON/ADON/Designee.
- Oversight will be provided by the Administrator/DON/Designee.
- Notification protocol and SBAR understanding will be tested by giving a test to LVNs and RNs that cover SBAR education and notification of physician regarding change of condition.
- Change of condition will be reported from shift to shift up to nurse management by utilizing the SBAR/eInteract process and 24-hour report tool and reviewed in clinical start-up with oversight provided by DON/ADON/Designee.
- DON/ADON/Designee will be responsible for reviewing SBAR/24-hour report/nurse to nurse huddle and hand-off at morning clinical start up.
- Discrepancies will be addressed with root-cause analysis and brought to QAPI with the oversight with the Medical Director.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during incontinent care for two residents. CNA J did not wash or sanitize her hands before applying gloves and improperly donned a gown, leaving parts of her body exposed. She used the same pair of gloves throughout the entire procedure, including when cleaning the resident's perineal area and applying a clean brief. After completing the care, she realized there was no hand sanitizer in the room and did not wash her hands before leaving. CNA D, while providing incontinent care to another resident, did not change her gloves or sanitize her hands before touching a clean brief after disposing of a soiled one. Although she washed her hands before leaving the room, she acknowledged her failure to sanitize and change gloves during the procedure, attributing it to nervousness. Both CNAs had been trained and competency-checked on infection control procedures, yet failed to adhere to the facility's policies during the observed care. The Director of Nursing (DON) confirmed that staff were expected to perform hand hygiene after touching a dirty area and before moving to a clean area during incontinent care. The facility's policies on perineal care and hand hygiene emphasize the importance of handwashing and glove use to prevent infection. Despite this, the observed deficiencies in hand hygiene practices placed residents at risk for cross-contamination and infection.
Food Safety and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen and resident nourishment rooms. Knives and serving utensils were improperly stored on a rack, exposing sanitized surfaces to potential contaminants from a nearby air duct vent. Additionally, various kitchen appliances and equipment were found soiled with grease and food residues, including a Cambro warmer cart and a manual can opener. The deep fryer unit contained dark cooking oil and food crumbs, and a cardboard box of diced potatoes was stored directly on the floor of the walk-in freezer. An ice scoop was improperly placed on top of the ice inside the ice machine. Further deficiencies were noted in the documentation and operation of the dishwashing process. Dishwasher A recorded water temperature and sanitizer levels for the low-temperature dish machine before actually running it, citing a concern about forgetting to document later. The dish machine log was not readily available in the dish machine room but was found in a separate cabinet. Additionally, the Memory Care Nourishment Room's refrigerator-freezer lacked an interior thermometer, and resident food was undated. The freezer compartment door gasket was loose, leading to icicles forming inside. Interviews with staff revealed a lack of adherence to policies and procedures for kitchen sanitation and equipment maintenance. The Dietary Manager acknowledged the need for inservice training for dietary staff and stated that the nourishment room refrigerator was the responsibility of the housekeeping department. The Registered Dietician Consultant and the ADON for the secure unit also recognized the need for training and policy review, indicating a systemic issue in maintaining food safety standards and equipment functionality.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #26, who had a complex medical history including unspecified dementia, anxiety disorder, major depressive disorder, bipolar disorder, and other mental health conditions, was prescribed antipsychotic medication Seroquel and mood stabilizing medication Nuedexta. However, these medications were not included in the resident's comprehensive care plan, nor were the indications for their use specified. The care plan also lacked details on mood state, mental health services, and the administration of Nuedexta for mood stabilization. Resident #61, diagnosed with Alzheimer's disease and other conditions, was admitted to hospice care services. Despite a significant change MDS assessment being completed due to this admission, the resident's comprehensive care plan did not address the hospice care services. The ADON acknowledged that hospice care should be included in the care plan and noted the absence of documentation regarding the hospice nurse's attendance during the care plan conference in the progress notes. The facility's policy and procedure for comprehensive person-centered care plans, revised in December 2016, requires that care plans include measurable objectives and timetables to meet residents' needs. The policy also mandates that care plan interventions be derived from a thorough analysis of comprehensive assessment information and that the interdisciplinary team includes appropriate staff or professionals as determined by the resident's needs. The deficiencies in the care plans for Residents #26 and #61 placed them at risk for not receiving necessary care and services to meet their individual needs.
Failure to Coordinate PASRR Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to coordinate the assessment for a resident with the Pre-Admission Screening and Resident Review (PASRR) program. The resident, a female with diagnoses of paranoid schizophrenia, bipolar disorder, and dementia, was not identified as having a mental illness on the PASRR Level One Screening Form. This oversight meant that the necessary PASRR 1012 form or a new PL1 form was not completed to initiate a PASRR evaluation by the local intellectual and developmental disability authorities. The resident's medical records indicated the use of psychotropic medications for her mental health conditions, yet the PASRR documentation did not reflect her mental illness diagnoses. Interviews with facility staff revealed that the MDS Coordinators were aware of the need for accurate PASRR documentation but failed to ensure the forms were completed correctly. The MDS Coordinator with forty years of experience acknowledged the error and stated that she was in the process of auditing diagnoses for all residents. The Regional Clinical Reimbursement Specialist confirmed that the PL1 form was not coded correctly for mental illness, attributing the failure to the previous MDS Nurses' lack of routine monitoring of diagnoses. The facility's policy on preadmission screening for mental illness was not adhered to, resulting in the deficiency.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for a resident prior to their installation. The resident, a female with a history of acute respiratory failure, lack of coordination, muscle wasting, muscle weakness, unspecified dementia, and a history of falling, was admitted to the facility without any documented orders or consent for bed rail use. Despite the absence of consent, observations revealed that bed rails were installed on both sides of the resident's bed. The resident's care plan and electronic health records did not reflect any assessment or informed consent for the use of bed rails. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that no side rail assessment was conducted for the resident. The DON acknowledged that assessments for side rails should be performed upon admission, readmission, quarterly, or with significant changes in the resident's condition. The facility's policy on the proper use of side rails emphasized the need for a side rail utilization assessment and obtaining informed consent from the resident or their legal representative. The lack of adherence to these procedures could potentially lead to negative outcomes such as entrapment.
Inadequate Infection Control Practices for C-Diff Isolation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) and inadequate hand hygiene practices. During an observation, a Licensed Vocational Nurse (LVN) was seen providing care to a resident on isolation precautions for Clostridium difficile (C-Diff) without wearing the required PPE, which includes a gown, gloves, and mask. The LVN admitted to forgetting to don the necessary protective gear and initially used hand sanitizer instead of washing hands with soap and water, which is ineffective against C-Diff. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the expectation for staff to use proper PPE and hand hygiene techniques, specifically soap and water, when dealing with C-Diff cases. The resident involved was a female with a history of enterocolitis due to C-Diff, Parkinson's Disease, and dehydration, and had been on isolation precautions since early August. The facility's policy on infection prevention and control, as well as CDC guidelines, emphasize the importance of contact precautions and proper hand hygiene to prevent the spread of infections. Despite these guidelines, the failure to adhere to established protocols placed residents at risk for cross-contamination and infection, as noted by the Director of Operations and other staff members during interviews.
Failure to Post Actual Nursing Staff Hours
Penalty
Summary
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff, including RNs, LVNs, and CNAs, who are directly responsible for resident care per shift daily. Observations on two separate days revealed that the daily nursing staffing information was posted but did not include the total numbers of actual hours worked for each type of nursing staff. This omission was noted during observations conducted on the mornings of both days. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator revealed a lack of awareness and adherence to the facility's policy regarding the posting of actual hours worked. The DON was unaware of the requirement until it was brought to her attention, while the ADON, responsible for staffing and daily postings, admitted to never including the actual hours worked. The Administrator acknowledged that the policy was not followed and stated that the form would be modified to meet the requirements. The facility's policy, last reviewed in July 2016, mandates that within two hours of each shift's start, the number of licensed and unlicensed nursing personnel and their actual hours worked must be posted in a prominent location.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that Resident #1's assessments accurately reflected her medical condition and needs. Specifically, the Admission MDS assessment did not accurately document the resident's skin integrity issues, treatments, and impairment in lower extremities. The resident's face sheet indicated she was admitted with sepsis, cellulitis of the right lower limb, and a local infection of the skin and tissue. However, the MDS assessment inaccurately reported that the resident did not have an impairment in her lower extremities and did not require pressure-reducing devices for her chair. Additionally, the MDS assessment incorrectly documented the presence of an unstageable pressure wound and failed to note moisture-associated skin damage, despite the resident having a Stage 3 pressure wound on her sacrum, a lymphademic wound on her right lower extremity, and a candidiasis rash of the abdomen as per the initial skin assessment and treatment records. Interviews with the Wound Care Nurse and the Director of Nursing (DON) confirmed the inaccuracies in the MDS assessment. The Wound Care Nurse stated that the resident did not have an unstageable pressure ulcer and did have an impairment in her lower extremities, as well as a pressure-reducing device in her chair. The DON acknowledged that the MDS nurse responsible for the assessment was no longer employed at the facility and that the inaccuracies were being corrected. The DON also confirmed that the incorrect MDS assessment could potentially affect the resident's care plan, although the actual care provided to the resident was consistent with her needs as documented in other records and observations.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission. Specifically, a resident admitted with diagnoses of sepsis, cellulitis of the right lower limb, and an unstageable pressure wound did not have a baseline care plan created or reviewed by an RN following their admission. The resident's clinical record showed no evidence of a baseline care plan being completed within the required timeframe. During an interview, the DON acknowledged that the baseline care plan form in the resident's EMR was not completed and was unsure who was assigned to complete it. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission to ensure residents' immediate care needs are met. However, this policy was not followed, potentially putting the resident at risk for not receiving necessary care and services from the time of admission.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain accurate and current clinical records for a resident, specifically in the areas of wound treatments, shower records, and bladder records. The resident, a cognitively intact female with a history of sepsis, cellulitis, and local skin infection, had several wound care orders that were not documented as completed on a specific date. Additionally, the resident's shower schedule was not accurately reflected in the electronic records, leading to discrepancies between the scheduled and actual shower days. The resident's bladder records were also inaccurately documented, showing inconsistencies in the resident's incontinence status. Interviews with the Wound Care Nurse and the Director of Nursing (DON) revealed that the wound care was performed but not documented, and the shower schedule was not correctly entered into the electronic system. The DON acknowledged that the resident's daily skilled evaluation contained inaccuracies and that the nursing staff had been trained on proper documentation procedures. The facility's policy on charting and documentation emphasized the importance of accurate record-keeping to facilitate communication among the interdisciplinary team, but this was not adhered to in this case.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. On 05/22/2024, it was observed that the daily staffing pattern posted on the wall by the copier room and the DON's office was outdated, showing the date 05/16/2024. The DON confirmed that the staffing information had not been updated or posted since 05/16/2024 and that the last posting was kept in a binder book instead of being displayed prominently. The ADON also confirmed that the staffing sheets were placed in a binder book at the front desk, which was not readily accessible to residents and visitors as required by the facility's policy and procedure dated July 2016. The facility's policy mandates that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care must be posted in a prominent location accessible to residents and visitors. The failure to update and post the daily staffing information could cause confusion regarding staffing and resident care issues. Both the DON and ADON acknowledged the oversight and mentioned that the staffing sheets were supposed to be kept at the front desk but were not posted as required. This deficiency could affect residents, their families, and facility visitors by not providing them with access to current staffing data and facility census information.
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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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