Lakeshore Village Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Waco, Texas.
- Location
- 2320 Lake Shore Dr, Waco, Texas 76708
- CMS Provider Number
- 675438
- Inspections on file
- 43
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Lakeshore Village Nursing And Rehabilitation during CMS and state inspections, most recent first.
PASARR Screening Not Updated for Mental Illness Diagnoses: The facility did not ensure PASARR Level I screenings accurately reflected the mental health status of 2 residents. One resident had schizophrenia and anxiety disorder documented, and another had PTSD, schizoaffective disorder, depressive type, and other psychiatric diagnoses, but both PASARR screens indicated no mental illness. MDS staff, the DON, and the ADM stated MDS was responsible for accurate PASARR completion and that diagnoses such as schizophrenia, major depressive disorder, severe anxiety, and PTSD would trigger a positive PASARR.
Food items in the kitchen were not properly labeled and dated in the refrigerator and freezer. An opened package in the freezer had no label or dates, an opened package of provolone cheese in the refrigerator lacked delivery and opened dates, and another frozen item had a delivery date and opened date but no disposal date. The DM, CK1, and ADM all stated food should be labeled and dated per facility policy.
Failure to Disinfect Reusable Blood Pressure Cuff Between Residents: An LVN used the same blood pressure cuff on three residents during med administration without disinfecting it between uses. The LVN stated she knew the cuff should be wiped with a sanitizing wipe between residents but did not do so. The DON and Administrator stated reusable equipment was expected to be cleansed between residents, and facility policy required reusable items to be cleaned and disinfected before reuse.
Failure to Post Daily Nurse Staffing Information: The facility failed to ensure daily nurse staffing information was posted accurately and was readily accessible to residents and visitors. During observation, the staffing census posting in the entrance area was dated with the prior day’s date. Interviews showed conflicting statements about who was responsible for posting the daily schedule, and the ADM stated there was no policy for the daily posting of the schedule.
An HHSC representative arrived at the facility to conduct a Priority One investigation and was instructed to wait in the lobby for the Administrator. When the Administrator arrived, he told the HHSC representative that they would need to send someone else because he had filed a complaint against that representative and that the resolution was that the representative would not be allowed back in the building. The HHSC representative subsequently left without conducting the investigation, despite state law and HHSC guidance allowing commission representatives to enter at reasonable times and requiring providers to grant surveyors access to records. Facility census records showed 123 residents were present at the time, and the report states that this failure placed all residents at risk of potential harm due to the P1 investigation not being conducted to rule out immediacy.
A resident with moderate cognitive impairment and limited vision was ambulating with a cane while an OT, responsible for supervision, was distracted by her phone and not paying attention. This inattention occurred despite facility policies and staff training prohibiting phone use during resident care, particularly during ambulation, and placed the resident at risk of accident or injury.
A resident with multiple comorbidities refused all nutrition and hydration for several meals, but staff failed to document the refusals or notify the responsible party and practitioners as required. The issue was only discovered when the resident was sent to the ER with acute encephalopathy, renal failure, and dehydration. Facility leadership and practitioners confirmed they were not informed of the resident's declining intake, and the facility's policies for notification were not followed.
A resident with complex medical needs refused all meals and fluids for multiple consecutive meals, but staff failed to document the refusals or notify the practitioner and responsible party as required. The lack of communication and documentation led to the resident being hospitalized with acute encephalopathy, renal failure, and severe dehydration.
The facility exhibited multiple deficiencies in food safety and sanitation practices, including improper food storage, labeling, and temperature maintenance. Staff failed to follow hygiene protocols, such as wearing proper hair restraints and using utensils for food handling. These actions could lead to cross-contamination and foodborne illnesses among residents.
The facility failed to ensure menus met nutritional needs, were prepared in advance, and reviewed by a dietitian. Observations revealed inadequate portion sizes served by hand, lack of menu documentation, and unapproved special meals. Staff interviews highlighted a lack of policy adherence, risking residents' nutritional intake and quality of life.
A resident with moderate cognitive impairment was subjected to an inappropriate comment by a CNA, who likened the resident's meal to "kitty litter." This incident, observed by a state surveyor, highlights a failure to uphold the resident's dignity and respect, as outlined in the facility's policies. The resident expressed discomfort with staff interactions, indicating a broader issue with staff communication.
The facility failed to ensure that call lights were within reach for three residents, including one with severe cognitive impairment and another who was cognitively intact but required assistance. Observations showed call lights out of reach, and staff interviews confirmed the expectation for call lights to be accessible at all times.
The facility failed to ensure residents' rights to choose meal options, as special meals served in the dining room were not offered to those who preferred to eat in their rooms or were bedridden. This practice affected four residents, who were unaware of the special meals and expressed a desire to have them delivered to their rooms. The dietary manager admitted the meals were not listed on the menu and were used as an incentive to encourage dining room attendance, contradicting the facility's policy on resident rights.
The facility failed to honor the food preferences of four residents, leading to dissatisfaction and potential nutritional issues. A resident with quadriplegia was served food against her preferences, while two residents with moderate cognitive impairment did not receive requested items like margarine. Another resident's request for hamburgers was not fulfilled due to errors in processing her request forms. These failures risked poor intake and diminished quality of life.
A resident with severe cognitive impairment had dirty glasses, which were not cleaned regularly, potentially impairing her vision and increasing fall risk. Staff interviews revealed inconsistencies in responsibility for cleaning glasses, with CNAs stating it was their duty, while the ADM and DON noted no specific policy for daily cleaning. The facility's ADL policy emphasized maintaining residents' abilities, but the lack of clear guidelines for cleaning glasses led to a deficiency.
The facility failed to secure medication carts, leaving them unlocked and unattended. Two medication carts were observed in hallways, unsupervised, with drawers facing outward. LVNs admitted to not locking the carts, contrary to facility policy. The DON and ADM confirmed that carts should be locked when not in use, as per the facility's policy.
A facility failed to implement its abuse prevention policies when an LPN reported an allegation of one resident ejaculating on another. The facility did not notify authorities or conduct a thorough investigation, placing residents at risk. The involved residents had cognitive impairments, and staff interviews revealed differing opinions on the nature of the substance found. The facility's policies for reporting and investigating abuse were not followed.
A facility failed to report an alleged abuse incident involving two residents within the required timeframe. An LPN reported suspicions of one resident ejaculating on another, but the DON dismissed the allegation, citing lack of evidence. The administrator and DON did not report the incident to the state, contrary to facility policy.
The facility failed to ensure that kitchen staff adhered to the policy requiring hairnets and beard restraints, as observed during a survey. Staff members, including a dishwasher and dietary aides, were found not wearing the necessary protective gear while handling food, despite being trained on the policy. This inconsistency in policy enforcement could lead to food contamination.
A facility failed to administer medications on time for a resident with multiple health conditions, leading to delays over several days. Additionally, another resident was found with oxycodone without an order, and the facility did not follow its controlled substances policy, resulting in untracked medication. These deficiencies risked improper medication therapy and potential drug diversion.
PASARR Screening Not Updated for Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that the PASARR Level I screening accurately reflected the status of 2 residents reviewed for PASARR screening. For Resident #1, the face sheet listed diagnoses including schizophrenia and anxiety disorder, and the care plan referenced antidepressants, antipsychotics, and antianxiety medications related to anxiety and schizophrenia. However, the PASARR Level I screening dated 03/12/2026 indicated no evidence of a primary diagnosis for the individual and did not reflect the mental illness diagnosis present on admission. For Resident #4, the face sheet listed diagnoses including PTSD, schizoaffective disorder, depressive type, auditory hallucinations, major depressive disorder, and altered mental status. The quarterly MDS dated 3/17/26 reflected a BIMS score of 14 and assistance needs with eating, toileting, showering, and personal hygiene. The PASARR Level I Screening dated 12/09/2025 marked Mental Illness as no, indicating the resident did not have a mental illness, despite the diagnosis of PTSD being present on admission and referenced in the care plan. During interviews, the MDS staff member stated MDS was responsible for ensuring PASARR was completed correctly and that diagnoses such as schizophrenia, bipolar disorder, major depressive disorder, severe anxiety, and PTSD would trigger a positive Level I PASARR. The DON and ADM also stated the MDS department was responsible for accurate PASARR completion and that inaccurate PASARR information could prevent residents from receiving eligible services. The facility policy stated residents with newly evident or possible serious mental disorder were to be referred promptly for a Level II resident review, and that the facility designee was responsible for tracking PASARR status and referring to the appropriate authority.
Food Items Not Properly Labeled and Dated
Penalty
Summary
Food was not stored in accordance with professional standards for food safety in the kitchen. On 04/20/26 at 9:02 AM, observation of the refrigerator and freezer found an opened package of small bite sized oval shaped pieces with a crumbly breaded coating and pale golden color that had no label, delivery date, opened date, or disposal date. An opened package of provolone cheese in the refrigerator had no delivery date or opened date, although it did have a used by date of 03/11/26. An opened package of French toast in the freezer had a delivery date of 03/10/26 and an opened date of 04/13/26, but no disposal date. During interviews, the DM stated food in the refrigerator and freezer should have three dates: the delivery date, the opened date, and a disposal date, and that all food items should be labeled. She stated the disposal date was between 3 and 5 days from the opened date depending on the product, and that she was responsible for checking food deliveries and ensuring the delivery date was written on each package. The CK1 also stated food should be labeled and have the three dates, and the ADM stated the facility had a food storage and dating policy and that the DM was responsible for ensuring it was followed. Record review of the food receiving and storage policy revised 10/2017 stated that all food stored in the refrigerator or freezer would be covered, labeled, and dated with a use by date.
Failure to Disinfect Reusable Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 3 residents reviewed for infection control when LVN A did not disinfect a reusable blood pressure cuff between residents during medication administration. During an observation on 4/21/2026 at 8:00 AM, LVN A used the blood pressure cuff on Resident #58, Resident #132, and Resident #120 without wiping it with a sanitizing wipe between each resident. During an interview on 4/21/2026 at 9:02 AM, LVN A stated she was frequently in-serviced on infection control and knew it was policy to cleanse the blood pressure cuff between residents, but she did not do so. She stated she had worked in the facility for 20 years and knew she should have wiped the cuff with a sanitizing wipe between each resident. The DON stated on 4/22/2026 at 10:38 AM that reusable medical equipment was to be cleansed between each resident, and the Administrator stated on 4/22/2026 at 12:42 PM that staff should cleanse reusable equipment such as a blood pressure cuff between residents. Facility policy titled Infection Prevention and Control Program stated reusable items and equipment were to be cleaned and disinfected according to procedure and manufacturer guidelines, and decontaminated with a germicidal detergent prior to storing for reuse.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 1 days reviewed, and the staffing information posted on 4/21/2026 was dated 4/20/2026. During an observation at 12:00 PM, the daily staffing census information was posted in the entrance area with the prior day’s date. During interviews, the DON stated it was her job to post the daily staffing and said nobody would know what the staffing would be. The ADM stated it was the DON’s job to post the daily schedule and said the negative outcome was that staff would not know their hours and where to go, adding that it was not posted but it was done. On 4/22/26, the ADON stated she was not responsible for posting the daily staffing and said the staffing coordinator was responsible, while the staffing coordinator stated the daily staffing posting was posted daily and that HR was responsible for posting it at the entrance. The ADM also stated there was no policy regarding the daily posting of the schedule.
Administrator Denies HHSC Surveyor Immediate Access for Priority One Investigation
Penalty
Summary
The deficiency involves the facility’s failure to allow immediate access to residents by a state representative of the Texas Health and Human Services Commission (HHSC) who arrived to conduct a Priority One (P1) investigation. On the morning in question, at about 8:55 a.m., an HHSC representative arrived at the facility and was instructed to wait in the lobby for the Administrator. At approximately 9:04 a.m., the Administrator came to the lobby and told the HHSC representative that they would have to send someone else because the Administrator had filed a complaint against that representative. The Administrator further stated that the resolution to his complaint was that the HHSC representative would not be allowed back in the building. Subsequent observation at about 9:47 a.m. showed the HHSC representative leaving the facility’s parking lot without having been allowed to conduct the P1 investigation. Census records reviewed by surveyors showed that there were 123 residents in the facility on that date. Record review of Texas Health and Safety Code Chapter 242, Section 242.043, indicated that the commission or its representative may enter an institution at reasonable times to conduct inspections, surveys, or investigations as necessary. Review of HHSC Provider Letter PL 18-26 stated that providers must grant access to all electronic health records when requested by a surveyor. The report states that this failure to allow entry placed all 123 residents at risk of potential harm due to a P1 investigation not being conducted to rule out immediacy.
Inadequate Supervision During Resident Ambulation Due to Staff Phone Use
Penalty
Summary
A deficiency occurred when an occupational therapist (OT) failed to provide adequate supervision to a resident with moderate cognitive impairment and limited vision. The resident, a male with a diagnosis of senile degeneration of the brain and ADL self-care performance deficits related to COPD and fatigue, was observed ambulating with a cane while the OT walked behind him, pushing his wheelchair. During this time, the OT was distracted by her phone, looking at pictures and not paying attention to the resident, contrary to facility policy and her training. Interviews with the OT, DON, and ADM confirmed that staff are not permitted to use personal phones during resident care, especially while providing mobility assistance, as outlined in the facility's policies. The OT acknowledged that her inattention could have resulted in serious injury if the resident had fallen. Facility records and interviews further confirmed that staff had received in-service training on the prohibition of phone use during resident care, and that the policy specifically prohibits therapy staff from using phones while ambulating patients.
Failure to Notify Responsible Party and Practitioners of Resident's Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's responsible party and practitioners when there was a significant change in the resident's physical status, specifically a deterioration in health. The resident, a male with a history of cerebral infarction, hypertension, neoplasm-related pain, heart disease, ataxia, and myocardial infarction, was admitted to the facility and subsequently refused to eat or drink from dinner on his admission day through breakfast two days later. Despite this refusal, there were no entries in the resident's progress notes regarding the lack of nutrition or hydration, nor any documentation that practitioners or the responsible party were notified of the situation. Staff interviews revealed that the CNA informed the charge nurse about the resident's refusal to eat or drink, and both attempted to encourage intake without success. However, the charge nurse did not document these refusals in the electronic medical record, citing being busy, and did not notify the responsible party or practitioners. The nurse also mistakenly believed the resident was his own responsible party. Practitioners who saw the resident during this period were not informed of the missed meals, and documentation in the point-of-care system only allowed for a 0-25% intake range, not a true 0% intake, further obscuring the severity of the issue. The responsible party was only notified when the resident was being sent to the emergency room after being found lethargic with low vital signs. Upon hospital evaluation, the resident was diagnosed with acute encephalopathy, acute renal failure, and profound dehydration. Interviews with facility leadership confirmed that there was an expectation for staff to notify management, the responsible party, and practitioners when a resident refused meals or hydration, but this did not occur in this case. The facility's own policies required prompt notification in such circumstances, but these were not followed, resulting in a significant lapse in care and communication.
Removal Plan
- Resident #1 no longer resides in the facility.
- DON/Designee initiated a full audit of all residents to identify any with poor intake or refusal trends. Residents identified with low or declining intake (<25%) were immediately evaluated by nursing. NP/MD and RP notifications initiated. Care plans updated accordingly by DON/Designee.
- DON was in-serviced by Regional Nursing to notify MD/NP and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations with return demonstration.
- DON/Designee will in-service licensed nursing staff/licensed agency re-educated and directed to notify Practitioner and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations. This will be added to licensed nurses' general orientation for new hires.
- Mandatory in-services will be completed with all current and oncoming nursing staff prior to start of shift worked.
- DON/Designee will complete competency validation conducted for licensed nurses/licensed agency on meal percentages documentation and training above per visual aides and return demonstration. This will be added to licensed nurses' general orientation for new hires.
- Administrator was in-serviced on department head meal manager schedule and details by Texas Area President.
- Department Heads will be in-serviced by administrator on meal manager requirements.
- DON/designee will monitor for residents with poor intake on PCC dashboard in the morning meeting or remotely daily to ensure that interventions are initiated, and Practitioner and RP are notified immediately but not later than 24 hours from identification of nutritional change. This will be documented on a monitoring tool.
- Any issues will be reported to the QAPI Committee meeting monthly.
- Administrator will lead Ad hoc QAPI to review the deficiency and the process for POR.
Failure to Notify and Document Resident's Refusal of Nutrition and Hydration
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including a recent stroke, heart disease, and ataxia, was admitted to the facility and subsequently refused all meals and hydration from dinner on the day of admission through breakfast two days later. Despite this refusal, there was no documentation in the resident's progress notes regarding the lack of nutrition or hydration, nor was there evidence that the practitioner or responsible party (RP) was notified of the resident's ongoing refusal. The care plan was updated only after the resident was sent to the emergency room, and meal intake documentation was limited to entries indicating 0-25% consumption, with no option to record 0% intake. Interviews with staff revealed that the certified nursing assistant (CNA) informed the charge nurse of the resident's refusal to eat or drink, but the charge nurse did not document these refusals or notify the practitioner or RP. The nurse stated she became busy and did not complete the required documentation or notifications. Nurse practitioners who saw the resident during this period were not informed of the missed meals and were unaware of the resident's poor intake until after the resident was found to be lethargic and was sent to the hospital. The responsible party was only notified when the resident was being transferred to the emergency room, and expressed that earlier notification could have allowed them to intervene. Upon arrival at the hospital, the resident was diagnosed with acute encephalopathy, acute renal failure, and profound dehydration, requiring admission for further treatment. The facility's own policy required notification of the physician and RP in cases of significant changes in intake or nutritional status, but this was not followed. Multiple staff, including the director of nursing, administrator, and medical director, confirmed that the expected protocol was not adhered to, and that the lack of communication and documentation contributed to the resident's decline.
Removal Plan
- Resident #1 no longer resides in the facility.
- DON/Designee initiated a full audit of all residents to identify any with poor intake or refusal trends.
- Residents identified with low or declining intake (25% or less) were immediately evaluated by nursing. NP/MD and RP notifications initiated.
- Care plans updated accordingly by DON/Designee.
- DON/Designee will in-service Licensed nursing/licensed agency staff re-educated and directed to notify Practitioner and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations. This will be added to licensed nurses' general orientation for new hires.
- DON/Designee will in-service CNAs/Agency CNA re-educated and directed to notify charge nurse of missed meals or poor intake (<25%), accurate documentation and communication expectations. This will be added to CNAs general orientation for new hires.
- Mandatory in-services will be completed with all current and oncoming nursing staff prior to start of shift worked.
- Competency for License staff and CNAs/Agency CNAs validation conducted on meal percentages documentation and training above per visual aides and return demonstration. This will be added to licensed nurses/CNAs general orientation for new hires.
- Administrator was in-serviced on department head meal manager schedule and details by Texas Area President.
- Department Heads will be in-serviced by administrator on meal manager requirements.
- DON/designee will monitor for residents with poor intake on PCC dashboard in the morning meeting or remotely daily for a period to ensure that interventions are initiated, and Practitioner and RP are notified immediately but not later than 24 hours from identification of nutritional change. This will be documented on a monitoring tool.
- Any issues will be reported to the QAPI Committee meeting.
- Ad hoc QAPI to review the deficiency and the process for POR will be completed.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in multiple deficiencies in food storage, preparation, and service. Observations revealed that food product bags in the freezer were left open, exposing them to air and causing freezer burn. Additionally, food items in the refrigerator and freezer were not labeled or dated, and a three-door freezer was not maintained at acceptable temperatures, leading to frozen foods thawing and refreezing without being discarded. These practices could potentially lead to cross-contamination and foodborne illnesses among residents. In the kitchen, staff members were observed not following sanitary practices. One staff member, identified as [NAME] H, was seen opening a package of food with his mouth, eating while cooking, and using gloved hands to portion food after touching multiple surfaces without changing gloves. Furthermore, proper hair restraints were not worn by staff, with beard guards not covering full facial hair, increasing the risk of contamination. The facility also failed to reheat and hold food at the proper temperature, as evidenced by chili being served at 110 degrees Fahrenheit, below the required 140 degrees Fahrenheit. The nourishment rooms also exhibited deficiencies, with refrigerators not maintaining proper temperatures and food items not being labeled with residents' names or dates. The facility's policies and training on food safety, hygiene, and labeling were not effectively implemented, as staff members were observed not adhering to these guidelines. Interviews with staff and management revealed a lack of awareness and action regarding these issues, further contributing to the deficiencies observed during the survey.
Failure to Adhere to Menu Planning and Portion Control Policies
Penalty
Summary
The facility failed to ensure that the menus met the nutritional needs of residents in accordance with established national guidelines. The menus were not prepared in advance, were not followed, and appropriate substitutions were not made. Additionally, the menus were not reviewed by the facility's dietitian or another clinically qualified nutrition professional for nutritional adequacy. This deficiency was observed in the kitchen where the Dietary Manager (DM) did not create a menu in advance for a special incentive lunch meal served in the dining room, and the menu was not reviewed or approved by the regional dietitian. During observations, it was noted that the DM served inadequate portion sizes during a lunch meal by not using the correct scoop size and serving food portions with hands, which is against the facility's policy. The facility also failed to document any substitutions made to the menus for soft mechanical and puree diets for ten residents. This lack of documentation and adherence to menu guidelines placed residents at risk of poor intake, possible weight loss, and diminished quality of life. Interviews with staff revealed a lack of awareness and adherence to policies regarding menu planning and portion control. The DM admitted to creating special meals without a formal process or policy, and there were no menus or meal tickets for these meals. The dietitian was not involved in the process and had not approved any menus for the special meals. The facility's policies on menu planning, portion control, and menu substitutions were not followed, leading to inconsistencies in meal service and potential nutritional inadequacies for the residents.
Resident Dignity Compromised by Inappropriate Staff Interaction
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as observed during an interaction between a CNA and a resident. The resident, who has moderate cognitive impairment and requires assistance with eating, asked the CNA about the lunch being served. The CNA responded inappropriately by saying, "Looks like you're going to be having kitty litter today," and then left the room. This interaction was witnessed by a state surveyor, and the resident later expressed that she would not have eaten the food if she had understood the comment, and mentioned that staff often made worse comments when surveyors were not present. The resident's care plan indicated she had several medical conditions, including high blood pressure, diabetes, and cognitive impairment, and required assistance with eating. The facility's policies on resident rights and abuse prevention emphasize treating residents with respect and dignity and prohibit any form of abuse, including verbal abuse. The facility administrator acknowledged the inappropriateness of the CNA's comment and noted that while abuse in-servicing was routinely conducted, there had not been a specific in-service on professional communication.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for three residents were within reach, which is a violation of resident rights and could potentially place residents at risk of unmet needs. Resident #99, a male with multiple diagnoses including pneumonia and myocardial infarction, was observed on two separate occasions with his call light out of reach, lying on the floor between the bed and the wall. His care plan specifically included the intervention of having the call bell within reach due to his physical functioning deficit and risk for falls. Resident #112, a male with severe cognitive impairment and multiple health issues, was also found with his call light out of reach on two occasions. Despite being dependent on staff for all activities of daily living, his care plan required that the call bell be within reach. Staff interviews revealed that although Resident #112 might not be capable of using the call light, it was still expected to be within reach as part of his care plan. Resident #72, who was cognitively intact but required assistance for daily activities, reported that his call light was placed out of reach after a CNA made his bed. He demonstrated that he could not reach the call light and expressed that he would have to yell or go into the hallway to get help. Interviews with staff, including CNAs and the ADM, confirmed that call lights should be within reach at all times, and failure to do so could lead to residents being unable to call for help when needed.
Failure to Offer Equal Meal Options to All Residents
Penalty
Summary
The facility failed to ensure that residents had the right to make choices about significant aspects of their lives, specifically regarding meal options. Four residents were affected by this deficiency, as they were not allowed to enjoy the special meals served in the dining room because they either preferred to eat in their rooms or were bedridden. This practice could potentially diminish residents' feelings of self-worth and quality of life. Observations revealed that a kitchen aide served chili cheese dogs with optional onions in the dining room, but these meals were not offered to residents who ate in their rooms. Interviews with the residents indicated that they were unaware of the special meals being served in the dining room and expressed a desire to have the option to enjoy these meals in their rooms. The dietary manager admitted that the special meals were not listed on the menu and were intended as an incentive to encourage residents to eat in the dining room. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, and ensuring a dignified existence. However, the practice of offering special meals only to those who dine in the dining room contradicts this policy. Staff interviews confirmed that there was confusion among residents about the availability of special meals, and some staff members expressed that all residents should have the option to enjoy the same meals, regardless of their dining location.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of four residents, leading to dissatisfaction and potential nutritional issues. Resident #9, who has quadriplegia and requires total assistance with eating, was served hamburger patties covered in gravy despite her meal ticket indicating a preference for no gravy or sauce. This occurred because the kitchen ran out of the planned menu item, and the staff did not inform the nurse or provide an alternative meal. Resident #11, with moderate cognitive impairment, consistently did not receive margarine and sweet and low with her meals, as indicated on her meal ticket. Despite her requests, the aides did not return to provide the missing items, leading to her reluctance to ask for assistance. Similarly, Resident #43, also with moderate cognitive impairment, did not receive margarine with his meals and was served oatmeal, which he disliked, despite his preferences being known to the staff. Resident #53, who is independent in eating, requested hamburgers for lunch but did not receive them, even though her family member filled out the necessary forms. The dietary manager acknowledged that errors in the dates on the forms might have led to the requests being ignored. The facility's failure to honor these residents' food preferences and provide appropriate substitutions as per their policies placed the residents at risk of poor intake and diminished quality of life.
Failure to Maintain Resident's ADL Abilities Due to Unclean Glasses
Penalty
Summary
The facility failed to ensure that residents were provided with the necessary care and services to maintain or improve their ability to perform activities of daily living (ADLs). Specifically, Resident #231, who was severely cognitively impaired with a BIMS score of 05, had dirty glasses with built-up grime on both lenses. This condition was observed on 02/19/25, and the resident reported that nobody cleaned her glasses except herself and the nurses, and they had not been cleaned in a long time. The resident's care plan indicated a risk for falls and injury due to poor safety awareness, and the lack of clean glasses could have impaired her vision, increasing the risk of falls. Interviews with staff revealed a lack of clarity and consistency regarding the responsibility for cleaning residents' glasses. The occupational therapist (OT) mentioned trying to keep the glasses clean during therapy sessions but was unsure who was ultimately responsible. Certified Nursing Assistants (CNAs) C and D stated that it was the CNAs' responsibility to clean the glasses daily, as part of their training to maintain residents' belongings. However, the Administrator (ADM) and Director of Nursing (DON) indicated that there was no specific policy requiring daily cleaning, only that glasses should be cleaned when dirty or upon request. The facility's policy on Activities of Daily Living (ADLs) emphasized providing care to maintain or improve residents' abilities to perform ADLs, including grooming and personal hygiene. However, the lack of a clear policy or consistent practice regarding the cleaning of glasses led to a deficiency in meeting the resident's needs. The facility's policy on cleaning and disinfection of resident-care items did not specifically address the cleaning of glasses, contributing to the oversight in ensuring Resident #231's glasses were kept clean to prevent potential vision impairment and associated risks.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, making them inaccessible to unauthorized staff, visitors, and residents. During an observation, two medication carts were found unattended and unlocked. Medication Cart #1 was located in Hall-B, against a wall across from the nurses' station, with its drawers facing outward. The cart was unsupervised, and no residents or staff were in sight. LVN-A admitted to leaving the cart unlocked after retrieving something from it and acknowledged that it should have been locked. Similarly, Medication Cart #2 was found in Hall-A, also against a wall across from the nurses' station, with its drawers facing outward. This cart was also unsupervised, with two residents nearby and multiple staff members moving around the area. LVN-B confirmed that medication carts should be locked unless in use. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the expectation was for medication carts to be locked when not in use. The facility's policy on the security of medication carts, revised in April 2007, stated that carts should be secured during medication passes, parked in the doorway of the resident's room with drawers facing inward, and locked when out of the nurse's view. The policy also required that when not in use, carts should be locked and parked at the nurse's station or inside the medication room. The failure to adhere to these policies could potentially allow unauthorized access to medications.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures regarding prohibiting and preventing abuse for one resident. The incident involved an allegation that one resident ejaculated on another resident, which was reported by an LPN via text message to the administrator. Despite the report, the facility did not notify local, state, and federal agencies as required by current regulations. The facility also failed to conduct a thorough investigation into the incident, which included not assessing all possible incidents of abuse and not reporting all allegations of abuse within the required timeframes. The resident involved in the incident had severe cognitive impairments and was non-verbal, with a history of sitting in laps of other residents and staff, and frequently chewing on his hands. The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. The alleged perpetrator was another resident with mild cognitive impairment and a history of delusions, but no prior history of inappropriate sexual behavior. The facility's failure to investigate the incident thoroughly and report it as required placed residents at risk of undetected abuse and potential harm. Interviews with staff revealed that the LPN and CNA believed the substance found on the resident's brief was semen, but the DON dismissed the allegation, suggesting it could be saliva. The administrator and DON did not document the investigation properly, failed to interview all relevant parties, and did not notify the ombudsman or the residents' representatives. The facility's policies required thorough documentation and reporting of such incidents, which were not followed in this case.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged incident of abuse involving two residents within the required two-hour timeframe. An LPN reported via text message to the administrator that she believed one resident had ejaculated on another resident. Despite this report, the facility did not immediately notify the State Agency, delaying the investigation into the allegation. This delay could have placed residents at risk for abuse and resulted in undetected abuse or psychosocial harm. Resident #1, a male with severe cognitive impairment and intellectual disabilities, was found with a fluid substance on his brief by a CNA during rounds. The LPN and CNA suspected the substance was semen and reported their concerns to the administrator and DON. However, the DON dismissed the allegation, suggesting the substance could be saliva, and instructed the LPN to discard the brief. The LPN felt the situation warranted an investigation, but her incident report was struck out by the DON, citing a data entry error. The administrator, who was traveling at the time, delegated the investigation to the DON, who concluded there was no abuse due to the lack of visible trauma or ill outcome for Resident #1. The administrator and DON did not report the incident to the state, as they collectively decided it was not a reportable incident. The facility's policy requires all allegations of abuse to be reported and investigated, but this protocol was not followed in this case.
Non-Compliance with Hairnet and Beard Restraint Policy in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically regarding the use of hairnets and beard restraints in the kitchen. During observations, it was noted that several staff members, including a dishwasher and dietary aides, were not wearing the required hairnets and beard restraints while preparing and handling food. This non-compliance was observed during a survey, where staff members admitted to not wearing the necessary protective gear, despite being trained and in-serviced on the policy. The facility's policy, revised in November 2022, clearly mandates that food and nutrition services staff must wear hair restraints to prevent hair from contacting food. Interviews with the staff revealed inconsistencies in the understanding and enforcement of the hairnet policy. Some staff members believed that only those on the service line or cooking needed to wear hairnets, while others acknowledged the requirement but failed to comply due to forgetfulness or misunderstanding. The Dietary Manager (DM) confirmed that training was provided, but there was a discrepancy in the enforcement of the policy, particularly regarding dishwashers. The DM stated that dishwashers were not required to wear hairnets according to the policy, yet she still instructed them to do so. This lack of consistent enforcement and understanding of the policy could potentially lead to physical contamination of food, posing a risk of foodborne illness to residents.
Medication Administration and Controlled Substances Policy Failures
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of Resident #2, as medications were not administered on time over several consecutive days. Resident #2, a male with multiple diagnoses including seizures, hypertension, and depression, reported receiving medications such as dicyclomine, Eliquis, Zoloft, lactulose, levetiracetam, and enalapril maleate late, often over an hour past the scheduled time. The medication aide, MA B, confirmed administering medications late due to her workload, which involved administering medications to 40 residents. Despite the resident's intact cognition and awareness of the late administration, there was no documentation of any negative effects from the delays. The facility also failed to implement its controlled substances policy when a bottle of oxycodone was found in Resident #3's possession without an order in place. Resident #3, who had diagnoses including chronic pain and major depressive disorder, was found with the medication on her first day at the facility. LVN B confiscated the oxycodone and locked it in the medication cart, but there was no documentation of the medication being prescribed to the resident or any subsequent tracking of the medication's disposition. The DON was not informed of the situation until much later, and there was no record of the oxycodone being destroyed or accounted for, raising concerns about potential drug diversion. The DON acknowledged that the facility's policy on timely medication administration was not followed, as medications should be administered within one hour before or after the scheduled time. The lack of documentation and communication regarding the oxycodone found with Resident #3 also indicated a failure to adhere to the facility's procedures for handling controlled substances. These deficiencies placed residents at risk of not receiving appropriate medication therapies and potential drug diversion.
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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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