Legend Oaks Healthcare And Rehabilitation Center -
Inspection history, citations, penalties and survey trends for this long-term care facility in Gladewater, Texas.
- Location
- 1201 Fm 2685, Gladewater, Texas 75647
- CMS Provider Number
- 676048
- Inspections on file
- 31
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Legend Oaks Healthcare And Rehabilitation Center - during CMS and state inspections, most recent first.
Failure to inform residents of their rights: Staff did not orally review or explain resident rights for 8 of 8 confidential residents reviewed. Resident council minutes did not show rights were discussed at multiple meetings, and 8 residents said staff had not reviewed their rights with them and could not verbalize any resident rights. The AD said she had not been aware she should be reviewing and explaining rights, while the ADM said residents received a written rights statement in the admission packet and were spoken to about rights as issues arose.
Delayed Resident Mail Distribution: The facility failed to ensure residents had timely access to incoming mail for 8 of 8 confidential residents reviewed. Residents stated they did not receive mail on Saturdays and expected mail that day if they were expecting it. The AD, ADM, and Transportation Manager gave inconsistent accounts of weekend mail retrieval, and the facility policy on Resident Personal Mail did not address Saturday mail distribution.
Grievance Information Not Made Available to Residents: The facility failed to make grievance information available to residents and their representatives. An observation found no grievance forms freely available, and the posted grievance policy was in English only. In a confidential group interview, residents stated they did not know how to file a grievance, had never seen the form, and were unaware they could file an anonymous grievance. The AD stated he had not reviewed the grievance process with residents and kept the form in his personal resident council binder, while an LVN could not find a grievance form.
Weekend Activities Not Provided to Residents: The facility failed to provide activities that matched resident interests and supported psychosocial well-being for 8 reviewed residents. Records showed no Sunday activities across multiple months and only church every other Saturday, while residents stated they wanted more weekend activities. The AD said there were no scheduled Sunday activities and believed that was acceptable, and the ADM said the resident council had requested more weekend activities but the minutes did not document that discussion.
Controlled drug count sheets were not completed correctly for two med carts. An RN signed both the coming-on and going-off shift sections at the same time on one cart, and an LPN did not sign as receiving the controlled count on another cart. The DON and Corporate Nurse stated nurses were to sign the controlled drug count record when coming on and going off shift, and the facility policy required both nurses to count, justify, and sign the narcotics supply at each shift change.
A resident with a Foley catheter and another resident with a suprapubic catheter were observed with tubing lying over their legs and bed edges without slack or any device to secure or anchor the tubing. Both residents had care plans and orders to monitor for pulling and prevent tension, kinking, and accidental removal, but staff observed and handled the tubing without preventing traction. The RN said she was responsible for catheter monitoring but could not explain how to identify pulling, while the DON said nurses were expected to look for slack in the tubing.
Unlocked Medication Cart Left Unattended: The Hall 100 med cart was observed at the nurse's station with the drawers closed but unlocked and unattended for about five minutes. The corporate nurse confirmed it should have remained locked, and an LVN stated he stepped away to speak with the DON about resident orders and failed to lock the cart. Facility policy required drugs and biologicals to be stored in locked compartments and accessible only to authorized personnel.
A facility failed to maintain consistent EBP identification for two residents. One resident had an EBP sign posted despite no order or clinical indication for EBP, while another resident with surgical drains had a pink dot on the door nameplate but no EBP sign at the room entrance. Multiple staff members did not know what the pink dots meant, and the DON stated the facility had just started using them and that staff on duty had not been in-serviced.
Missing Most Recent Survey Results in Accessible Binder: The facility failed to keep the most recent standard survey in the survey binder located by the front entrance and accessible to residents, family members, and legal representatives. The ADM stated he was responsible for keeping the binder current, believed the survey was included, then confirmed it was missing after review. Eight residents reported they did not have access to the most recent survey results and wanted to review them, and the facility policy titled Required Postings did not address posting the most recent survey results.
Failure to Post Daily Nurse Staffing Data: The facility did not post the required nurse staffing information in a clear, readable, and prominent location for residents and visitors. Observations found outdated staffing data still posted on a hallway wall, with no current-day posting anywhere in the facility. The DON said the Staffing Coordinator was responsible for daily posting, and the ADONs and DON shared monitoring duties, but the information had not been updated.
A resident with post-stroke hemiplegia, bowel incontinence, and full dependence for toileting reported that a CNA failed to return to provide incontinence care after responding to a call light, leaving the resident sitting in fecal matter for an extended period and allegedly refusing to assist, with disrespectful behavior. The resident’s family member corroborated key aspects of the timeline and reported the allegation to the Administrator. The CNA stated she had provided care twice within a shorter timeframe and denied disrespectful conduct. The Administrator, after being informed of the allegation and speaking with the resident, concluded the incident was a customer service issue rather than neglect and did not report the allegation to the state agency within the required 24-hour period, contrary to facility policy and regulatory reporting requirements for alleged abuse/neglect.
A resident with dementia, lack of coordination, a history of multiple recent falls, and moderate cognitive impairment was care planned as a high fall risk and used a wheelchair for mobility, independently propelling with her feet while needing substantial assistance for transfers and footwear. On observation, she was in the dining room twice wearing non-slip-resistant socks, with one sock slipped below the heel, while self-propelling her wheelchair. Nursing and CNA staff, as well as the ADON and Administrator, acknowledged she was a major fall risk with recent injury and that fall interventions included anti-slip socks or shoes, and that she should have been wearing appropriate footwear. This was inconsistent with the facility’s fall management policy requiring an environment as free of accident hazards as possible and appropriate interventions to prevent falls.
The facility failed to ensure that three residents had their call lights within reach, compromising their ability to communicate needs and increasing the risk of unmet needs. A resident with severe cognitive impairment and physical limitations, another with moderate cognitive impairment and physical deficits, and a third with mild cognitive impairment and a history of falls were all found with call lights out of reach. Staff interviews confirmed the importance of this practice, yet it was not consistently followed.
A LTC facility failed to securely store medications for three residents, leading to potential health risks. One resident had barrier cream and a medication cup on the bedside table, another had Miconazole Nitrate cream without a corresponding order, and a third had Silvadene and stoma powder without documented orders. Staff interviews revealed confusion about proper storage, contrary to the facility's policy requiring secure storage accessible only to authorized personnel.
A long-term care facility failed to maintain proper infection control practices, leading to deficiencies in care. A resident received improper incontinent care, increasing the risk of UTIs. Another resident's isolation room was cleaned with a disinfectant not effective against Clostridium difficile, risking infection spread. Additionally, a nurse did not change gloves or sanitize hands after catheter care, risking cross-contamination.
A facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, as the resident's oxygen concentrator was observed with a dirty filter containing gray debris. The resident, with a history of cerebrovascular disease and pneumonia, was dependent on staff for many activities of daily living. Facility staff acknowledged the oversight, noting that the concentrator filters should be cleaned weekly, as per facility policy.
The facility failed to ensure that a dietary aide had a current Food Handler's Certificate, which is necessary for safe food handling. The Dietary Manager admitted to not verifying the certification status, leaving it to the aide to renew. The deficiency was identified when the aide's certification was found expired, and it was only renewed after the surveyor's inquiry.
A resident with severe cognitive impairment and dysphagia was served ice water instead of nectar-thickened liquids, as required by her care plan. Despite signage and documented dietary restrictions, a CNA was unaware of the resident's needs, leading to a potential risk of aspiration. Interviews with staff highlighted a lack of communication and awareness regarding the resident's dietary requirements.
A resident with severe cognitive impairment was recorded undressed by an RN, who shared the video with staff, leading to a deficiency in protecting the resident from abuse. The incident was not reported promptly, and the RN was later terminated.
A resident with dementia was filmed without consent by an RN, who shared the video with other staff, violating facility policies. The incident was not reported to the state agency promptly, and the RN continued working for nearly a month after the incident. The facility's delay in action left the resident vulnerable to further abuse, highlighting a significant lapse in protecting residents from abuse and neglect.
A resident with severe cognitive impairment was videoed without consent by an RN while naked, and the video was shared among staff without being reported to the abuse coordinator or state agency in a timely manner. The facility's administrator was informed but did not investigate or report the incident promptly, allowing the video to circulate and compromising the resident's dignity. The incident was eventually reported to the police, leading to the RN's termination.
A resident with severe cognitive impairment was videoed naked by a nurse, RN A, who shared the video with other staff. The facility's administration, led by Administrator G, failed to promptly investigate or report the incident, allowing RN A to continue working for nearly a month. The resident was unaware of the incident due to dementia, and the facility's inaction resulted in a period of Immediate Jeopardy, indicating a serious threat to resident safety.
A facility failed to maintain effective pest control, resulting in a fly outbreak and maggots in a resident's wound. The resident, with a chronic ulcer and other medical conditions, had maggots discovered during a dressing change. Despite monthly pest control visits, the measures were insufficient, leading to the infestation. Interviews and observations indicated the fly problem had improved, but the initial failure highlighted a significant deficiency in pest control efforts.
Two residents did not receive proper wound care as per physician orders, with Hydrofera Blue not moistened before application, contrary to instructions. One resident's boot was improperly fitted, causing discomfort. Staff interviews revealed a lack of knowledge about the correct use of Hydrofera Blue, leading to inadequate care.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure residents were informed orally of their rights for 8 of 8 confidential residents reviewed for resident rights. Record review showed resident council minutes did not document that resident rights were reviewed or discussed at multiple meetings, and the minutes for one meeting only indicated “yes” without stating which rights were reviewed. During a confidential interview, 8 confidential residents stated staff had not discussed or reviewed their rights with them, and all 8 were unable to verbalize any of their rights as residents. An observation of the facility bulletin board showed resident rights postings in English and Spanish. During interviews, the AD stated she was not aware she should have been reviewing and explaining residents’ rights, though she believed it was important for residents to know their rights and said she would be responsible for ensuring they knew them. The ADM stated all staff were responsible for ensuring residents knew their rights and said residents were provided a written statement of rights in the admission packet and were spoken to about their rights as issues arose. The facility policy stated it was the policy to inform the resident both orally and in writing of his/her rights, as well as the rules and regulations governing conduct and responsibilities during the stay.
Delayed Resident Mail Distribution
Penalty
Summary
The facility failed to ensure residents had reasonable access to receive their mail in a timely manner for 8 of 8 confidential residents reviewed for mail. During a confidential group interview, the 8 residents stated they did not receive mail on Saturdays and expected to receive mail that day if they were expecting it. The facility did not have a system in place to distribute incoming mail daily and ensure residents promptly received their mail. During interviews, the AD stated she was responsible for ensuring residents received mail on weekdays and that she went to the post office and delivered mail to residents throughout the week, but she was unsure whether the post office was open on Saturdays. The ADM stated he was unsure if staff could obtain mail on weekends, while also stating the AD and transportation manager alternated weekends to obtain mail. The Transportation Manager stated she was on call every other weekend, went to the post office to obtain mail, and distributed it to residents, and that if a resident was expecting mail and did not receive it, she would expect them to be upset. A review of the facility policy titled Resident Personal Mail, last updated 06/2017, showed it did not address receiving and distributing mail on Saturdays.
Grievance Information Not Made Available to Residents
Penalty
Summary
The facility failed to make information available to residents and their representatives on how to file grievances for 7 of 8 confidential residents reviewed. During an observation on 04/13/2026 at 3:15 PM, no grievance forms were available for residents or their representatives to freely access, and the grievance policy posted on the bulletin board was in English only. In a confidential group interview, 7 confidential residents stated they were unaware of how to file a grievance, 7 said they had never seen the grievance form, and 8 were unaware they could file an anonymous grievance. During interviews on 04/14/2026, the AD stated all staff were responsible for grievances, but he had not reviewed with residents how to file a grievance and kept the grievance form in his personal resident council binder. The AD also stated residents were not given information on how to file an anonymous grievance and that he did not go over the formal grievance process with new admissions. The SW stated she had only been employed at the facility for 5 days and would soon go to resident council to ensure residents were aware of their right to file a grievance. LVN B stated he was unable to find a grievance form and would bring a resident to the AD if they wanted to file a grievance.
Weekend Activities Not Provided to Residents
Penalty
Summary
The facility failed to provide activities designed to meet each resident’s interests and support physical, mental, and psychosocial well-being for 8 of 8 confidential residents reviewed for activities. A record review of the last 6 months showed that the activities calendars for November 2025 through April 2026 had no activities available for residents on Sundays, and on alternate weekends there was church available but no activity scheduled for the other weekend. During confidential interviews, 8 confidential residents stated they did not have weekend activities other than church every other Saturday and said they wanted more activities on the weekend. During interviews, the AD stated she was at the facility every other Saturday to assist with the scheduled church activity and that a recently hired assistant would be able to help with the alternating Saturday. The AD stated residents did not have any scheduled activities for Sundays and believed it was okay for residents to not have a scheduled activity on Sundays. The ADM stated he believed there were weekends with enough activities and said the resident council had informed him in September 2025 that they wanted more weekend activities. The resident council minutes for September 2025 did not include the ADM name under Staff Members in Attendance and did not show that weekend activities were discussed. The facility policy stated residents have the right to choose activities and that daily activities, including weekends and holidays, are provided.
Controlled Drug Count Sheets Not Signed at Shift Change
Penalty
Summary
The facility failed to ensure a system was established for records of receipt and disposition of all controlled drugs in sufficient detail to allow accurate reconciliation, and failed to ensure controlled drug records were maintained and periodically reconciled for 2 of 4 licensed nurse medication carts observed for pharmacy services. On Cart #300 hall, RN A signed the controlled substance count sheets for the end of the shift at the beginning of the shift on 04/14/2026. On Cart #100 hall, LVN B did not sign as receiving the controlled substance count sheets at the beginning of the shift on 04/14/2026. During observation on 04/14/2026, RN A was seen signing on and off at the same time on the controlled drugs count sheet for Cart #300 hall, and LVN B had not signed for receiving the controlled count on Cart #100 hall. In interview, RN A stated she always signed both coming and going slots at the same time so she would not forget at the end of her shift, and LVN B stated he almost always signed the controlled count sheet when receiving control of the count but had forgotten that day. The Corporate Nurse and DON stated each nurse was to sign the controlled drug count record when coming on and going off shift, and the DON said she had in-serviced all nurses on the procedure. The facility policy stated that one nurse going off duty and one nurse coming on duty must count and justify narcotics supply at each shift change, and each nurse must record the date and signature verifying the count is correct.
Urinary Catheters Not Secured or Anchored
Penalty
Summary
The facility failed to ensure appropriate care for two residents with urinary catheters by not securing or anchoring the tubing to prevent pulling, tension, or kinking. Resident #2 was a female with dementia, chronic kidney disease, intra-abdominal and pelvic mass, and obstructive uropathy, and her care plan and physician orders included monitoring the catheter for pulling and changing the leg strap weekly and as needed. During observation, she was lying in bed with a Foley catheter tubing running over her right leg and over the edge of the bed to the collection bag, with no slack and no leg strap or other device in place to secure the tubing. Resident #3 was a male with obstructed and reflux uropathy, urethral abscess, and surgical aftercare following genitourinary surgery. He had a suprapubic catheter, and his care plan and physician orders included monitoring the catheter for pulling causing tension and securing the catheter to prevent kinking and accidental removal. During interview, he stated he could feel the tubing lying on his leg and did not recall anything being used to keep it from being pulled. During wound care observation, the suprapubic catheter tubing was seen extending from the lower abdomen over the resident’s left leg and over the edge of the bed to the collection bag, with no slack and no device in place to secure it. While staff moved the urine collection bag from one side of the bed to the other and back again, the tubing was passed over the resident’s lower body without any action to prevent pulling. The RN stated she was responsible for monitoring urinary catheters for proper care but could not describe how she would know if a catheter was being pulled or positioned in a way that placed tension on the bladder or urethra. The DON stated nurses were expected to monitor for pulling by looking for slack in the tubing.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls and that only authorized personnel had access to the keys for one of four medication carts, the Hall 100 medication cart. During observation, the cart was found at the nurse's station with the drawers closed but unlocked and unattended for approximately five minutes, with no residents or visitors observed around it. During interview, the corporate nurse stated the cart should remain locked when unattended and acknowledged it was left unsecured. LVN B stated he stepped away to speak with the DON about orders for a resident for the medical director and failed to lock the cart. LVN B also stated the cart should remain locked at all times when not under direct supervision of authorized personnel and that leaving it unlocked and unattended violated facility policy. Record review of the facility's Medication Access and Storage policy stated that all drugs and biologicals are to be stored in locked compartments under proper temperature controls and are accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
Inconsistent EBP Identification and Posting
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for residents requiring enhanced barrier precautions (EBP). During observations on Hall 400, Resident #27 had an EBP sign posted at the entrance to the room even though the resident’s record, including the face sheet, quarterly MDS, and physician’s orders, did not show a diagnosis or order supporting EBP. The resident had dementia, colostomy status, a BIMS score of 2, and was dependent on staff for most ADLs. The ADON stated the sign had been posted because the resident had a colostomy, then acknowledged during interview that colostomies did not require EBP and that staff had forgotten to remove the sign. Resident #65 had diagnoses including COPD, surgical after care for pseudoaneurysm with placement of JP drains, and pleural effusion. His 5-day MDS showed a BIMS score of 6, severe cognitive impairment, dependence on staff for most ADLs, and surgical wounds. His physician’s orders included EBP due to surgical drains following surgery on the circulatory system. During observation, a pink dot was present beside his name on the door nameplate, but there was no EBP sign posted at the room entrance. Staff members observed on the hall, including an LVN, the AD, a Transportation Person, and a PT, stated they did not know what the pink dots meant. The DON later explained that the pink dots were intended to identify which resident in a room required EBP, while the doorway sign indicated that someone in the room required EBP. She stated the facility had just started using the pink dots and that the nursing staff working that day had not been in-serviced on their use. The DON also found an EBP sign on top of a box in the hallway and placed it at Resident #65’s room entrance. The facility policy stated staff should be trained to identify when EBP are needed, that nursing staff should ensure residents and staff are aware of the need to use EBP, and that the infection preventionist should conduct regular audits of adherence.
Missing Most Recent Survey Results in Accessible Binder
Penalty
Summary
The facility failed to post its most recent standard survey in the survey binder located next to the front entrance, an area accessible to residents, family members, and legal representatives. On 04/13/2026 at 3:25 PM, observation of the binder showed that it did not include the results from the most recent standard survey completed on 02/12/2025. During an interview on 04/13/2026 at 3:35 PM, the ADM stated he was responsible for keeping the survey binder up to date and believed the most recent standard survey was in the binder. After reviewing it, he recognized that the survey was missing and stated that if a resident requested to review the survey results while he was not present, they would not be readily available. During a confidential group interview, 8 residents stated they did not have access to the most recent standard survey results and wanted to review them. Record review of the facility policy titled Required Postings, revised 05/2025, did not address posting the most recent standard survey results in an area accessible to residents, family members, and legal representatives.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post the nurse staffing data on a daily basis in a clear and readable format in a prominent, readily accessible place for residents and visitors. The report states that the required staffing information, including the facility name and the number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care, was not posted for 7 of 7 days reviewed, from 04/07/2026 through 04/13/2026. During observation on 04/13/2026 at 08:35 AM and again at 09:15 AM, the nurse staffing data for 04/06/2026 was still posted on the wall at the beginning of Hall 300, and no daily staffing data was posted for 04/13/2026 anywhere in the facility. In interviews, the ADON-C, ADON-D, and DON stated that the staffing information was intended to show residents and families how the facility was staffed for the current day, and the DON identified the Staffing Coordinator as responsible for posting it daily. The DON also stated that the posting had not been updated for the day of 04/13/2026 and that the 04/06/2026 posting had not been changed for a week.
Failure to Timely Report Allegation of Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the state agency within the required 24-hour timeframe. A cognitively intact female resident with hemiplegia and hemiparesis following a stroke, who was totally dependent on staff for toileting and frequently bowel incontinent, reported that on a specific evening she requested assistance for incontinence care after receiving a laxative and experiencing diarrhea. She stated that a CNA responded to her call light, said she needed to gather supplies, and then did not return. The resident reported that when she activated the call light again, the CNA told her she only had to change the resident every two hours, refused to change her brief or provide her name, and stuck her tongue out and rolled her eyes before leaving the room. The resident stated she remained sitting in fecal matter for over an hour, felt she was not being treated like a human being, and became afraid to press her call light because she did not trust anyone to help her. Her family member, who had been present earlier that evening, corroborated that the resident had requested to be changed and that the CNA initially responded but did not return before the family member left the building. The family member later received a distressed call from the resident reporting she still had not been changed and that the CNA had refused to assist her and had behaved disrespectfully. The family member then returned to the facility, confronted the CNA, and reported the allegations to the Administrator. The CNA later stated she was new to the facility, acknowledged being informed that the resident needed to be changed, and reported that she changed the resident once shortly after being notified and again 35–40 minutes later, denying any disrespectful behavior. The Administrator stated he was notified by the family member that evening that the resident had several large bowel movements and had not been changed for two hours, and the resident reported to him that the CNA had turned off the call light, said she would return, and then stuck her tongue out and rolled her eyes. The Administrator determined the situation was more related to customer service than neglect, believed neglect required harm or injury, and therefore did not report the allegation to the state agency within 24 hours, despite facility policy defining neglect as failure to provide necessary goods and services that are necessary to avoid physical harm, pain, mental anguish, or emotional distress and requiring that all allegations of abuse and neglect be reported to outside agencies within applicable timeframes.
Failure to Ensure Appropriate Footwear for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents. A female resident with diagnoses including heart failure, chronic respiratory failure, muscle wasting and atrophy, dementia, lack of coordination, and a history of falling was readmitted to the facility and assessed as having moderate cognitive impairment (BIMS 12). The MDS documented that she used a wheelchair for mobility, could independently propel herself in the wheelchair, and required substantial/maximal assistance with transfers, lower body dressing, and putting on/taking off footwear. Her care plan, revised earlier in the month, identified her as at risk for falls with actual falls on four prior dates, including one fall that resulted in facial bruising and a hematoma requiring hospital evaluation. Incident reports for these falls did not identify improper footwear as a pre-disposing factor. On the survey date, observations showed the resident self-propelled her wheelchair into the dining room using her feet while wearing red and green socks without an anti-slip surface, and later sitting in the dining room playing bingo with the same non-slip-resistant socks, with one sock slipped down beneath her heel. Multiple staff interviews, including with an RN, CNAs, an LVN, the ADON, and the Administrator, confirmed that the resident was considered a major/significant fall risk with recent fall injury and lack of safety awareness, and that fall interventions for at-risk residents included wearing anti-slip socks or shoes. Staff also stated that this resident should have had anti-slip footwear on to prevent falls and that not having appropriate footwear in the dining room could result in additional falls and injury. The facility’s fall management policy stated it was the facility’s policy to provide an environment as free of accident hazards as possible and to provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, which is a critical aspect of accommodating their needs and preferences. Resident #2, a female with severe cognitive impairment and physical limitations due to a stroke, was observed with her call light hanging off her bedside table, out of reach. Despite being able to communicate, she expressed difficulty in locating her call light, which is essential for her to request assistance given her condition. Resident #27, a male with moderate cognitive impairment and physical deficits following a subarachnoid hemorrhage, also had his call light placed out of reach on his bedside table. His inability to lift his left arm further complicated his ability to access the call light, which is crucial for his safety and ability to communicate needs, especially considering his medical history. Resident #52, a female with mild cognitive impairment and a history of falls, was found with her call light lying on her bed, out of reach while she was seated in a chair. She reported a recent fall while trying to reach for an item, highlighting the importance of having the call light accessible. Interviews with staff, including CNAs, LVNs, and the DON, confirmed that ensuring call lights are within reach is a shared responsibility, yet this was not consistently practiced, leading to unmet needs and potential risks for the residents.
Medication Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to securely store medications and biologicals for three residents, leading to potential health risks. Resident #2 had three packets of Thera calazinc barrier cream and a medication cup with a white substance on the bedside table. This resident, who was moderately cognitively impaired, had a history of hemiplegia and was at risk for skin breakdown due to incontinence. The presence of these items at the bedside was not in compliance with the facility's medication storage policy. Resident #27 had Miconazole Nitrate 2% cream on the bedside table without a corresponding order in the resident's medical records. This resident, also moderately impaired, had a history of seizures and hemiplegia. The cream was reportedly used for jock itch, but its presence at the bedside was not authorized, and staff interviews revealed a lack of clarity on whether such items could be stored in resident rooms. Resident #163 had Silvadene and Adapt stoma powder on the bedside table, with no documented orders for these medications. This resident had a history of cellulitis and a urostomy, requiring careful management of skin and wound care. Staff interviews indicated confusion about the proper storage of these items, with some staff members unaware of the facility's policy on medication storage. The facility's policy clearly stated that medications should be stored securely and only accessible to authorized personnel, which was not adhered to in these cases.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One incident involved improper incontinent care provided to a resident with a history of dementia and incontinence. During the care, a CNA wiped from the top of the resident's buttocks down towards the perineal area, which is contrary to the proper technique of wiping from front to back. This improper technique was acknowledged by the CNA and other staff members, who recognized the risk of urinary tract infections (UTIs) due to such practices. Another deficiency was noted in the cleaning practices for a resident's isolation room. The resident was diagnosed with Clostridium difficile, a highly infectious bacterium. The housekeeping staff used a disinfectant cleaner that was not effective against Clostridium difficile spores, as confirmed by the Environmental Protection Agency (EPA) registration details. The housekeeping supervisor and other staff members acknowledged the risk of spreading the infection to other residents due to the use of an inappropriate cleaning agent. Additionally, a nurse failed to change gloves or sanitize hands after performing catheter care for a resident with a suprapubic catheter. The nurse touched clean items with contaminated gloves, which could lead to cross-contamination and infection. This lapse in proper infection control practices was recognized by the nurse and other staff members, who understood the importance of changing gloves and sanitizing hands between dirty and clean procedures to prevent infections.
Failure to Maintain Clean Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as evidenced by the unclean condition of the resident's oxygen concentrator. The resident, a male with a history of cerebrovascular disease, enterocolitis due to Clostridium difficile, and pneumonia due to Mycoplasma pneumoniae, was observed on multiple occasions with an oxygen concentrator that had a dirty filter containing gray debris. The resident's care plan indicated a focus on oxygen therapy related to ineffective gas exchange, with interventions including continuous oxygen via nasal prongs as ordered by the physician. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Operations Manager, revealed that the oxygen concentrator filters were expected to be cleaned weekly. However, the dirty filter was likely overlooked during the resident's hospital stay. The facility's policy on oxygen equipment, last revised in May 2007, stated that oxygen concentrator filters should be cleaned with water and detergent every week or according to the manufacturer's recommendations. The failure to maintain the oxygen concentrator in a clean condition could place residents at risk for respiratory complications.
Deficiency in Food Handler Certification for Dietary Staff
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and accreditations in the food and nutrition service department, specifically concerning Dietary Aide A. The deficiency was identified when it was discovered that Dietary Aide A did not possess a current and valid Food Handler's Certificate, which is necessary for safe food handling and preventing foodborne illnesses. The Dietary Manager (DM) provided an employee list indicating that Dietary Aide A was hired in January 2021, and his Food Handler's Certificate had expired in November 2024. It was only after the surveyor's inquiry that Dietary Aide A completed the necessary certification on February 10, 2025. Interviews with the DM and other staff revealed a lack of oversight and responsibility in ensuring that all kitchen staff maintained valid certifications. The DM admitted to leaving the responsibility of certification renewal to Dietary Aide A and acknowledged the oversight in not reminding him. The Director of Nursing (DON) and the Operations Manager (OM) both emphasized the importance of having current certifications for all kitchen staff to ensure resident safety. The facility's Infection Control Policy outlined the need for education on personal hygiene and food handling, but there was no verification process in place to ensure compliance with these requirements.
Failure to Provide Nectar-Thickened Liquids to Resident with Dysphagia
Penalty
Summary
The facility failed to provide liquids consistent with the needs of a resident, specifically Resident #21, who required nectar-thickened liquids due to dysphagia. On February 11, 2025, CNA C served ice water to Resident #21, despite the resident's care plan and room signage indicating the need for nectar-thickened liquids. This oversight was discovered during an observation where a pitcher of ice water was found on Resident #21's bedside table, contrary to the dietary restrictions outlined in her care plan. Resident #21, an elderly female with severe cognitive impairment and a history of dysphagia, was at risk of aspiration due to the facility's failure to adhere to her dietary requirements. Her comprehensive care plan, revised on October 30, 2024, clearly stated the need for nectar-thickened liquids to prevent potential fluid deficits and swallowing problems. Despite these documented needs, CNA C was unaware of the resident's dietary restrictions and placed a pitcher of ice water in her room, which could have led to choking or aspiration. Interviews with various staff members, including CNAs, an OT, an LVN, the ADON, the DON, and the Operations Manager, revealed a lack of communication and awareness regarding Resident #21's dietary needs. Staff members acknowledged the potential negative effects of providing thin liquids to a resident requiring thickened liquids, such as aspiration and pneumonia. The facility's policy on nutrition status management emphasized the importance of assessing and meeting each resident's nutritional needs, yet this policy was not effectively implemented in the case of Resident #21.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a registered nurse (RN A) recorded the resident on her personal cellphone while he was undressed from the waist down. The incident occurred on 07/26/24, and the video was shared with other staff members. The resident, who had severe cognitive impairment due to dementia, was not aware of the recording. The video showed the resident's genitals and was accompanied by laughter from RN A, who found the situation humorous. The incident was not immediately reported to the facility administration or the police. It was only after the compliance department became involved that the administration was notified on 08/22/24. RN A was suspended pending investigation and was later terminated. The investigation revealed that multiple staff members were aware of the video, and some had seen it, but none reported it to the appropriate authorities. The delay in reporting and the sharing of the video among staff members contributed to the deficiency. The resident involved had a history of dementia, depression, and anxiety, and required supervision with most activities of daily living. Despite the resident's cognitive impairment, the facility's failure to protect his dignity and privacy resulted in a violation of his rights. The incident was classified as mental abuse, as defined by CMS, due to the demeaning and humiliating nature of the recording and its distribution among staff.
Failure to Prevent and Report Resident Abuse
Penalty
Summary
The facility failed to implement and enforce its policies and procedures to prevent abuse, neglect, and exploitation of residents, as evidenced by an incident involving a resident who was filmed without consent by a registered nurse (RN A). The video, which showed the resident naked from the waist down, was shared among staff members, including RN B, LVN C, CNA D, and others, who failed to report the incident immediately to the Abuse Coordinator. The facility's policy clearly prohibits the taking and sharing of photographs or videos that demean or humiliate residents, yet this policy was not adhered to by the staff involved. The incident was not reported to the state agency in a timely manner, as required by the facility's policy. The facility administrator, Administrator G, was informed of the video on July 31, 2024, but failed to initiate an investigation or report the abuse to the state agency. Instead, RN A continued to work until she was suspended on August 22, 2024, nearly a month after the incident occurred. This delay in action left the resident vulnerable to further potential abuse and demonstrated a significant lapse in the facility's responsibility to protect its residents. The resident involved, who had a history of dementia, depression, and anxiety, was not immediately protected from further abuse following the incident. The facility's failure to act promptly and appropriately in response to the abuse allegation placed the resident at risk for continued abuse and neglect. The facility's noncompliance was identified as posing an immediate jeopardy to the resident's safety and well-being, which was not resolved until August 30, 2024, after the survey began.
Failure to Report and Investigate Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were reported immediately or within the required two-hour timeframe. This deficiency involved a resident with severe cognitive impairment, who was videoed without consent by a registered nurse (RN A) while naked from the waist down. The video was shared among several staff members, including an RN, LVNs, a CNA, a transport aide, and a staffing coordinator, none of whom reported the incident to the abuse coordinator or state agency in a timely manner. The facility's administrator, Administrator G, was informed of the video but did not initiate an investigation or report the incident to the state agency promptly. Despite being aware of the video's existence and its inappropriate nature, Administrator G's response was limited to advising staff about the potential legal implications of such videos. The delay in reporting and investigating the incident allowed the video to circulate among staff, further compromising the resident's dignity and privacy. The incident was eventually reported to the police, and an investigation confirmed that RN A had taken and distributed the video. The facility's Director of Nursing (DON) was only made aware of the video's content weeks after it was recorded, leading to the suspension and eventual termination of RN A. The failure to report and address the incident promptly placed residents at risk for ongoing abuse and neglect, highlighting significant lapses in the facility's abuse reporting protocols.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was videoed by a nurse while naked from the waist down. The video was taken by RN A and shared with other staff members, which was not reported or addressed promptly by the facility's administration. The incident was initially brought to the attention of the facility's Administrator, Administrator G, who failed to take immediate action to investigate or report the incident, allowing RN A to continue working until she was suspended nearly a month later. The resident involved, an elderly male with severe cognitive impairment due to dementia, was unaware of the incident. Despite the resident's cognitive condition, the facility's staff, including the Administrator, failed to protect the resident from further potential abuse and did not ensure the resident's dignity and privacy were maintained. The video was shared among several staff members, who also failed to report the incident, contributing to the delay in addressing the abuse allegation. The facility's lack of timely response and investigation into the abuse allegation resulted in a period of Immediate Jeopardy, indicating a serious threat to the health and safety of the residents. The incident was eventually reported to the police, and RN A was terminated following the investigation. However, the facility's initial inaction and failure to protect the resident from further abuse highlight significant deficiencies in handling abuse allegations and ensuring resident safety.
Pest Control Deficiency Leads to Maggot Infestation in Resident's Wound
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an outbreak of flies and maggots found in a resident's wound. The resident, a male with a history of a non-pressure chronic ulcer on his right foot, was admitted with several medical conditions including hemiplegia and mild cognitive impairment. On June 1, 2024, maggots were discovered in the resident's wound during a dressing change, indicating a severe lapse in pest control measures. The facility's pest control log indicated a monthly visit targeting house flies and ants, but it was insufficient to prevent the fly outbreak. Interviews with residents and staff revealed that flies were a problem a few weeks prior, but the situation had improved after the installation of fly light traps. Despite these measures, the presence of maggots in the resident's wound suggests that the pest control efforts were not timely or effective enough to prevent the infestation. Observations and interviews conducted on June 19, 2024, showed that the fly problem had largely been resolved, with only occasional sightings. However, the initial failure to control the fly population led to the maggot infestation in the resident's wound, highlighting a significant deficiency in the facility's pest control program. The facility's staff, including the DON and treatment nurse, were aware of the issue but could not determine how the maggots entered the wound, as it was typically covered with a bandage and sock.
Improper Wound Care and Equipment Use
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and professional standards for two residents. Resident #2 did not receive the physician-ordered wound care as specified, which included the use of Hydrofera Blue that required moistening before application. Additionally, Resident #2's care plan included the use of a boot to prevent further injury to his right foot, but the boot was not appropriately fitted, causing discomfort and potential harm. During an observation, it was noted that the resident's foot was swollen, and the wound care was not performed according to the manufacturer's instructions, as the Hydrofera Blue was not moistened before application. Resident #1 also did not receive proper wound care as per the physician's orders. The resident had stage 4 pressure ulcers, and the treatment involved the use of Hydrofera Blue, which was not moistened before application by the LVN. This was contrary to the product's instructions, which required moistening with sterile saline or water. The LVN incorrectly believed that the product would soften on the wound, leading to improper wound care. Interviews with staff revealed a lack of knowledge regarding the correct use of Hydrofera Blue. The DON acknowledged that the LVN was not aware of the proper application method, and an in-service training was planned to address this issue. The facility's care planning policy emphasized the development of a comprehensive care plan by the interdisciplinary team, but the execution of these plans was inadequate, leading to deficiencies in resident care.
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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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