Legend Oaks Healthcare And Rehabilitation - Waxaha
Inspection history, citations, penalties and survey trends for this long-term care facility in Waxahachie, Texas.
- Location
- 151 Country Meadows Boulevard, Waxahachie, Texas 75165
- CMS Provider Number
- 676421
- Inspections on file
- 35
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Legend Oaks Healthcare And Rehabilitation - Waxaha during CMS and state inspections, most recent first.
Two residents experienced failures in required notifications regarding significant changes in status and care decisions. One resident with dementia and other comorbidities was transferred to another facility’s memory care unit without prior notification to her RP; staff interviews showed that multiple staff assumed others had notified the family, and there was no documentation of timely communication. Another resident with severe cognitive impairment and multiple medical conditions was found on a floor mat by CNAs, who reported the event to the nurse; the nurse did not treat the event as a fall, did not notify the RP or MD, and did not document the incident. Days later, a nurse identified bruising and pain in the resident’s arm, notified the NP, and obtained x-rays that revealed an acute humeral head fracture, with the RP only informed of the injury and imaging, not the earlier fall.
Two residents did not receive care consistent with professional standards and facility policy. One resident with cellulitis and multiple chronic conditions was discharged home after completing IV antibiotics, but staff failed to obtain an order for and remove his PICC line, and the discharge assessment omitted any mention of the line. Another resident with severe cognitive impairment and identified fall risk was found on a floor mat by CNAs, who reported the event to the charge nurse; however, the nurse did not document the fall, perform or document a post-fall assessment, notify the provider or family, or complete an incident report. The fall was only discovered days later when a nurse noted bruising and pain in the resident’s arm, leading to imaging that revealed an acute humeral head fracture, contrary to the facility’s fall management policy requiring assessment, documentation, and notification after a fall.
A resident with multiple chronic conditions did not have several medications and treatments properly documented in the electronic medical record. Staff confirmed that medications and treatments, including insulin, pain management, and catheter care, were administered but not signed off in the MAR due to competing duties. The facility's policy requires complete and accurate documentation, and leadership acknowledged that unsigned records indicate care may not have been provided.
A resident with severe cognitive impairment and complex medical needs was found to have a Statutory Durable Power of Attorney (DPOA) executed with facility staff as agents and witnesses, creating a conflict of interest. The DPOA was implemented during a period when the resident's capacity to consent was in question, and no appropriate external agent or guardian was secured, despite legal and hospital staff concerns.
A resident with severe cognitive impairment and multiple diagnoses continued to have an active yeast infection listed on her care plan after treatment had ended. Facility staff, including the ADON, DON, and ADM, confirmed that the care plan was not updated to reflect the resolved condition, contrary to facility policy requiring timely and accurate care plan updates.
A resident with a history of mobility issues suffered a skin tear during a transfer due to inadequate staff assistance. After hospitalization, the facility failed to arrange a follow-up appointment with a wound care specialist as instructed in the discharge papers. This oversight led to the resident missing the appointment, resulting in an infection and increased anxiety about her condition. Interviews revealed a breakdown in communication and procedure for scheduling follow-up appointments.
A resident with Parkinson's disease and mobility issues was injured during a transfer from a wheelchair to a bed when a CNA attempted the transfer alone, contrary to the care plan requiring two-person assistance. The resident's leg was caught on the bed, resulting in a severe laceration that required hospitalization and a blood transfusion. The facility also failed to ensure the resident attended a follow-up wound care appointment.
A resident with Parkinson's disease and reduced mobility was injured during a transfer by a CNA who did not use a gait belt or seek additional assistance. The resident's leg was lacerated, requiring hospitalization and a blood transfusion. The facility failed to report the incident to the state agency within the required timeframe, despite the resident's ability to articulate the event and the facility's policy mandating immediate reporting.
A resident with Parkinson's Disease and limited mobility was unable to reach the call light paddle due to improper placement by staff, leaving him unable to call for assistance. Despite facility policies requiring call lights to be within reach, the resident's call light paddle was consistently placed out of reach, leading to feelings of helplessness and reliance on staff for assistance.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in their documented speech clarity. One resident was observed to communicate only through gestures, while another was unable to respond verbally or with gestures, yet both were documented as having clear speech. These inaccuracies placed the residents at risk of receiving incorrect care.
The facility failed to implement comprehensive care plans for two residents, leading to potential risks. One resident's care plan lacked instructions for using a mechanical lift for transfers, while another's did not include required Enhanced Barrier Precautions. Staff interviews revealed confusion and reliance on informal communication methods, highlighting deficiencies in care planning and policy adherence.
A facility failed to monitor a resident for side effects of Apixaban, an anticoagulant medication. The resident, with multiple diagnoses, received the medication twice daily without any side effect monitoring in place. Interviews with staff revealed a lack of adherence to the facility's policy on monitoring blood thinner side effects, which is considered necessary to avoid classifying the medication as unnecessary.
A resident with multiple medical conditions reported receiving cold or lukewarm meals, with staff reluctant to reheat food, citing regulations. The resident spent significant money on outside food due to dissatisfaction. An LVN stated the procedure was to provide a new tray rather than reheating, and reheating was limited to kitchen staff during kitchen hours.
A long-term care facility failed to maintain an effective infection prevention and control program, resulting in deficiencies for two residents. A CNA did not follow proper hand hygiene protocols during perineal care for a resident, while another resident's room lacked signage and PPE for Enhanced Barrier Precautions. The facility's policies on infection control were not effectively implemented, posing a risk of cross-contamination and infection.
Two residents experienced neglect in a facility due to their soiled clothing not being taken to the laundry, leading to strong odors in their rooms. Despite requests for assistance, staff failed to address the issue, causing residents to feel neglected and embarrassed. Interviews revealed confusion among staff about laundry responsibilities, although facility policies indicated CNAs were responsible for laundry collection.
Two residents experienced neglect in maintaining a clean and homelike environment due to their soiled personal clothing not being taken to the laundry. Both residents' rooms had strong odors of urine and body odors, with overflowing laundry baskets identified as the source. Interviews revealed confusion among staff regarding the responsibility for laundry collection, contributing to the deficiency.
A resident in an LTC facility was mistakenly given three times the prescribed dosage of Requip, leading to symptoms such as dizziness and weakness. The error was due to a CMA misreading the order, and although the resident experienced distress, no significant adverse reactions were observed by the medical staff.
A resident with Alzheimer's and dysphasia choked and was hospitalized due to the facility's failure to assist and monitor her during meal service, despite clear hospice orders and family warnings.
The facility failed to develop and implement a comprehensive care plan for a resident requiring supervision or assistance while eating. Staff provided conflicting information about the resident's needs, and observations confirmed the resident was left to eat without necessary assistance. The care plan and care profile were not updated to reflect the resident's needs accurately.
Failure to Notify Physician and Responsible Party of Transfer and Fall Events
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with residents’ physicians and notify residents’ representatives of significant changes in condition and transfer decisions. For one resident with Alzheimer’s disease, hypertension, and atrial fibrillation, the facility transferred her to another nursing facility’s memory care unit without prior notification to her responsible party (RP). Progress notes showed that the resident was newly admitted, pleasantly confused, and exhibiting exit-seeking behavior, leading to placement of a Wanderguard. The following day, a nurse documented that the resident was discharged and transported to another facility, and that the family collected the resident’s belongings. However, the family member reported they were only called the morning of the transfer and told the resident was being moved and that they needed to pick up her belongings, with no prior notice or opportunity to participate in the decision. Interviews with staff confirmed that no one had clearly taken responsibility for notifying the RP about this transfer. The Admissions Director stated she spoke with the family when the resident was leaving but acknowledged she had not called the RP beforehand and had assumed another staff member had done so. The nurse who documented the discharge stated she did not call the RP because she believed the family was already aware, based on their presence later that day to collect belongings. A CNA who also worked as a social worker assistant stated she typically would contact the RP about transfers, discuss facility options, and send clinical information once a facility was chosen, but she was not aware of this resident’s discharge until after it occurred and had not contacted the RP or sent clinical information. The Administrator stated his expectation was that staff would have communicated with the RP prior to transfer or discharge, but he acknowledged there was no documentation of such communication. The deficiency also includes the facility’s failure to notify a resident’s RP and physician after a fall. A second resident, an older female with acute respiratory failure with hypoxia, type 2 diabetes, cognitive communication deficit, hypertension, muscle weakness, and severe cognitive impairment (BIMS score of 1), had a care plan identifying her as at risk for falls due to dementia, weakness, and an unsteady gait. A CNA reported finding this resident on her floor mat by the bed on an evening in mid-March and stated she notified the charge nurse, with another CNA corroborating that the nurse came into the room and saw the resident on the floor mat. The CNAs stated their role was to report falls to the charge nurse, who was then responsible for notifying the RP and medical providers. The nurse identified by the CNAs denied that the resident had fallen and stated he did not recall any such report, and therefore did not notify the RP or physician, complete an assessment, or initiate an incident report. Subsequently, another nurse performing a weekly skin assessment noted bruising and pain with movement in the resident’s right upper arm and notified the nurse practitioner, who ordered x-rays. The progress note documented that the RP was notified of the injury and x-ray order, but there were no notes indicating that the RP had been notified of a fall. Radiology results showed an acute right humeral head fracture in osteoporotic bone. The family member stated they were informed only of the bruising and x-ray and were unaware of the earlier fall until informed by the surveyor. The nurse practitioner and physician both reported they had not been notified of a fall at the time it occurred; the nurse practitioner stated she was only notified of the arm injury and ordered imaging, and the physician stated he learned of the fall after the fact. Facility policies on Resident Rights and Fall Management required immediate information to the resident when there is a decision to transfer or discharge, and required that the attending physician and resident representative be notified when a resident sustains a fall, but these procedures were not followed for these two residents.
Failure to Remove PICC at Discharge and Failure to Assess and Report Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one male resident with cellulitis of both lower limbs, muscle weakness, hypertension, atrial fibrillation, chronic heart failure, and chronic kidney disease, the facility did not ensure removal of a peripherally inserted central catheter (PICC) line upon discharge after completion of IV antibiotics. His admission MDS showed a BIMS score of 13, indicating no cognitive impairment. The discharge summary and discharge assessment documented completion of IV antibiotics for cellulitis, no skin issues, and no special instructions, but did not mention the PICC line, and there was no order in the record for PICC removal. The resident’s care plan, which was closed shortly after discharge, reflected that he had been receiving IV antibiotics for cellulitis, but there was no documentation that the PICC was addressed at discharge. The attending MD later stated he was not aware the resident had been discharged with the PICC still in place until after the fact, and that standard of care is to remove PICC lines prior to discharge unless there is a specific reason to keep them. He stated the resident had completed antibiotic therapy and should have had the PICC removed prior to discharge. The DON reported she became aware the resident went home with the PICC still inserted and that she obtained a telephone order from the NP the following morning to remove it, then went to the resident’s home with another nurse to remove the line and assess the site. The family member reported noticing the PICC still in the resident’s arm that evening at home and calling the facility, and the resident himself stated he realized later that day that the PICC remained in his arm and then notified his family. The administrator stated his expectation that PICC lines be removed prior to discharge unless there is an order to keep them and that staff should have obtained an order to remove the line once antibiotics were completed. The nurse who completed the discharge assessment stated she knew the resident had been on IV antibiotics but did not remember or realize he still had a PICC line at the time of discharge. She reported that she did not see a PICC line when she discharged him and did not specifically look for one because he had completed his antibiotics, and she was not aware he went home with the line in place or that staff later went to his home to remove it. She stated that if a resident has a PICC at discharge, staff are supposed to notify the RN on duty because only RNs can remove PICC lines, but she did not notify the RN because she did not know the line was still present. The facility’s PICC line removal procedure, when requested, did not contain instructions or guidance on removal of PICC lines prior to discharge. The deficiency also involves the facility’s failure to assess, document, and report a fall and possible injury for a female resident with acute respiratory failure with hypoxia, type 2 diabetes, cognitive communication deficit, hypertension, and muscle weakness, whose BIMS score of 1 indicated severe cognitive impairment. Her care plan identified her as at risk for falls related to dementia, weakness, a foot ulcer, and unsteady gait/transfers, with a goal to minimize risk of injury. Progress notes from the period surrounding the alleged fall contained no entries documenting a fall or post-fall assessment. Several days later, a nurse performing a body assessment noted bruising on the resident’s right upper arm and pain with movement, documented these findings, and notified the NP and family, leading to x‑rays that showed an acute right humeral head fracture. A CNA reported finding the resident on her floor mat by the bed on an evening shift and hearing a thud just before discovering her on the floor. She stated she notified the charge nurse and that another CNA assisted in bringing the resident to the nurse’s station. Both CNAs reported that the nurse lifted the resident under her arms into a wheelchair and that they did not observe the nurse perform a physical assessment, take vital signs, or check pupils at that time. They stated the resident did not cry out or show facial expressions of pain and that they did not see visible bleeding. One CNA later informed the DON about the fall when she learned of the resident’s injury and discovered the fall had not been reported. The charge nurse involved stated he did not notify the MD, resident representative, or family about a fall because he believed the resident had not fallen and did not recall the CNA reporting a fall. He acknowledged that if a resident fell, the nurse would be responsible for notifying family and providers, completing an assessment, and doing an incident report, but reiterated he was unaware of any fall and therefore did not complete an assessment. The DON stated she learned of the fall from the CNA and that, during her interview with the nurse, he initially denied a fall had occurred and later said the resident had been found on her fall mat but he did not count it as a fall, so he did not report it or make notifications. The NP and MD both stated they were not informed of a fall at the time it allegedly occurred and described expectations that staff assess residents after falls and notify providers so that injuries can be identified and treated. The facility’s Fall Management System policy required that when a resident sustains a fall, a physical assessment be completed by a licensed nurse with results documented in the medical record, and that the attending physician and resident representative be notified of the fall and resident status.
Incomplete Documentation of Medication and Treatment Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards and practices. Specifically, there were multiple instances where medication administration and treatments were not documented in the electronic medical record (PCC) for a resident with significant medical needs, including diabetes, muscle weakness, hypertension, and congestive heart failure. The resident's care plan included interventions for diabetes management, pain control, and suprapubic catheter care, all of which required consistent documentation to ensure continuity of care. Record reviews revealed that several medications and treatments, such as insulin administration, lidocaine patch application, air mattress checks, barrier cream application, and suprapubic catheter care, were not signed off as completed on the Medication Administration Record (MAR) on specific dates. Interviews with the involved staff confirmed that these medications and treatments were administered, but the staff failed to document them at the time of administration. The staff cited being occupied with other duties as the reason for the lack of timely documentation. The facility's policy on documentation and charting emphasizes the importance of maintaining a complete account of resident care, including medications and treatments, to guide physicians, measure quality of care, and serve as a legal record. Both the Director of Nursing (DON) and the Administrator acknowledged that failure to sign off on the MAR indicates that the medication or treatment may not have been given, which could have implications for the resident's care. The resident interviewed did not report any missed medications or treatments and expressed satisfaction with the care received.
Improper Execution of DPOA and Conflict of Interest in Resident Rights
Penalty
Summary
The facility failed to ensure a resident's rights to self-determination and a dignified existence by improperly executing a Statutory Durable Power of Attorney (DPOA). The DPOA was completed with facility staff members named as agents and witnesses, which created a conflict of interest and a dual relationship between the resident and staff. The DPOA was implemented during a period when the resident's capacity to consent was in question, as evidenced by medical documentation indicating severe cognitive impairment and a medical opinion recommending guardianship due to incapacity. Despite this, staff proceeded with the DPOA process without prior legal consultation and without securing an appropriate external agent or guardian. The resident involved had a complex medical history, including a recent femur fracture, type 2 diabetes with a foot ulcer, cerebral infarction, and a cognitive communication deficit. The resident was admitted from an acute care hospital and was listed as his own financial responsible party, with a niece and other contacts declining to serve as POA due to personal or religious reasons. The resident's cognitive status was noted to fluctuate, and assessments showed severe cognitive impairment. Despite these factors, facility staff members were named as agents in the DPOA, and the document was witnessed and notarized by another staff member, further compounding the conflict of interest. Interviews with facility staff revealed that the DPOA was not reviewed by the legal department until after its execution, and the hospital social worker raised concerns about its legality. The facility's legal counsel later advised that guardianship should have been sought instead of staff serving as agents. Documentation also showed that no formal guardianship application had been filed, and the staff members named in the DPOA continued to be listed as legal agents. The facility's own policies emphasized residents' rights to self-determination and participation in care decisions, but these were not upheld in this case due to the improper handling of the DPOA and failure to secure an appropriate decision-maker for the resident.
Failure to Update Care Plan After Resolution of Yeast Infection
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, specifically neglecting to update the care plan to reflect the resolution of a yeast infection. The resident, an elderly female with diagnoses including essential primary hypertension, unspecified dementia, and depression, had a severe cognitive impairment as indicated by a BIMS score of 1. Her care plan continued to list an active yeast infection even after the prescribed course of Terconazole vaginal suppositories was completed, and treatment had ended. Interviews with facility staff, including the ADON, DON, and ADM, confirmed that the care plan was not updated to indicate the yeast infection had resolved. The ADON acknowledged responsibility for updating the care plan and admitted to missing this update. The DON and ADM both stated it was expected for the care plan to be updated to reflect the resident's current condition. Facility policy requires the interdisciplinary team to develop and maintain comprehensive care plans with measurable objectives and timeframes, but this was not followed in this instance.
Failure to Arrange Follow-Up Wound Care Appointment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically by not arranging a follow-up appointment with a wound care specialist. The resident, who had a history of muscle weakness, reduced mobility, and Parkinson's disease, suffered a skin tear during a transfer from a wheelchair to a bed. This incident occurred because only one staff member was present, despite the resident requiring assistance from two people for transfers. The resident was subsequently hospitalized, received a blood transfusion, and was discharged with instructions to follow up with a wound care specialist. Upon discharge, the resident was supposed to have a follow-up appointment with a wound care doctor, but the facility failed to arrange this appointment. The resident's discharge papers clearly indicated the need for a follow-up on a specific date, but the facility did not read the discharge papers thoroughly and did not schedule the appointment. As a result, the resident missed the appointment, which led to the development of an infection in the wound. The resident expressed anxiety and concern over the missed appointment and the condition of her leg, which was exacerbated by the delay in receiving appropriate wound care. Interviews with facility staff revealed that there was a breakdown in communication and procedure regarding the scheduling of follow-up appointments. The nursing staff were responsible for reviewing discharge documentation and coordinating with the transporter to schedule appointments, but this process was not followed correctly. The facility's Director of Nursing acknowledged the importance of follow-up appointments for continuity of care but could not confirm if the missed appointment directly caused the infection. The deficiency highlights a failure in the facility's processes to ensure residents receive timely and necessary medical follow-up care.
Inadequate Supervision During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for Resident #162 during a transfer from a wheelchair to a bed, resulting in a significant injury. The incident occurred when a CNA attempted to transfer the resident alone, despite the resident's care plan indicating the need for two-person assistance. During the transfer, the resident's leg was caught on the bed, leading to a severe laceration that required hospitalization, a blood transfusion, and stitches. Resident #162, a woman with Parkinson's disease and other mobility issues, was admitted to the facility with a care plan that required substantial assistance for transfers. On the day of the incident, the CNA attempted to transfer the resident without the necessary support, leading to the resident's leg being injured on the bed's mobility bar. The resident was on anticoagulant therapy, which exacerbated the bleeding from the wound. The facility's failure to follow the care plan and provide adequate supervision during the transfer placed the resident at risk of physical harm. Additionally, the facility did not ensure the resident attended a follow-up appointment with a wound care doctor, as indicated in the hospital discharge papers. This oversight further contributed to the resident's risk of complications from the injury.
Failure to Report Neglect After Resident Injury
Penalty
Summary
The facility failed to report an incident of neglect involving a resident who required assistance with transfers due to multiple medical conditions, including Parkinson's disease and reduced mobility. On the day of the incident, a CNA attempted to transfer the resident from a wheelchair to a bed without the required assistance of a second staff member. During the transfer, the resident's leg was injured, resulting in a significant laceration that required hospitalization and a blood transfusion. The facility did not report this incident to the state agency within the required two-hour timeframe. The resident, who had a BIMS score indicating no cognitive impairment, reported that the CNA did not use a gait belt initially and did not heed her warnings about her leg being caught during the transfer. The resident's medical records indicated she was on anticoagulant therapy, which contributed to the severity of the bleeding from the laceration. Despite the resident's ability to articulate the events, the facility did not consider the incident as neglect or mistreatment, and thus did not report it as required by their policy. Interviews with staff and observations of the equipment involved in the transfer revealed discrepancies in the accounts of how the injury occurred. The maintenance director and other staff inspected the mobility bar and found no sharp edges that could have caused the injury, yet the CNA suggested the injury might have been caused by the bed frame. The facility's policy required immediate reporting of such incidents, but this was not adhered to, placing residents at risk of continued neglect.
Resident Unable to Access Call Light Paddle
Penalty
Summary
The facility failed to ensure that Resident #23's call light paddle was placed within reach, which compromised the resident's ability to call for assistance. Resident #23, diagnosed with Parkinson's Disease and moderate cognitive impairment, had limited mobility and was dependent on staff for most activities of daily living. Despite the resident's physical limitations, the call light paddle was consistently placed out of reach, rendering the resident unable to summon help when needed. Observations on multiple occasions revealed that the call light paddle was positioned near the top outer edge of the resident's right shoulder, a location inaccessible due to the resident's limited range of motion in both arms. Interviews with the resident confirmed feelings of helplessness and reliance on staff to check on him, as he was unable to activate the call light paddle independently. The facility's policy required that call lights be within reach, yet this was not adhered to, as evidenced by the resident's inability to access the call light paddle. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), highlighted the importance of ensuring call lights are accessible to residents, especially those with physical limitations. Despite this understanding, the facility's safeguards, such as regular room rounds and spot checks, failed to ensure the call light paddle was within reach for Resident #23. This oversight placed the resident at risk of unmet medical needs and psychosocial harm, as he was unable to call for assistance when necessary.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. Resident #18's MDS inaccurately reflected her speech clarity as clear, despite observations and interviews indicating she could only make unarticulated sounds and relied on gestures for communication. Her care plan acknowledged her communication challenges due to aphasia, yet the MDS did not align with her actual condition as observed by the surveyor and reported by staff. Similarly, Resident #58's MDS inaccurately documented her speech clarity as clear, while observations showed she was unable to respond verbally or with gestures. Her care plan noted her risk for communication problems due to aphasia and other conditions, but the MDS did not accurately reflect her severe communication impairments. Interviews with staff confirmed her inability to speak due to her medical conditions, and her recent SLUMS assessment indicated severe cognitive impairment. These inaccuracies in the MDS assessments for both residents placed them at risk of receiving incorrect care and services, as the assessments did not accurately reflect their communication abilities and needs. The facility's policy requires comprehensive and accurate assessments, yet the discrepancies in the MDS documentation for these residents highlight a failure to adhere to these standards.
Deficiencies in Care Planning for Resident Transfers and Precautions
Penalty
Summary
The facility failed to implement a comprehensive care plan for two residents, which could potentially compromise their care and safety. For one resident, the care plan did not specify the use of a mechanical lift for transfers, despite the resident's need for substantial maximal assistance due to conditions such as spastic hemiplegia and muscle weakness. Observations and interviews revealed that staff were unclear about the resident's transfer status, and the care plan lacked specific instructions on the level of assistance required. This lack of clarity could lead to unsafe transfers, as noted by staff members who expressed concerns about the potential for injury or falls. Another resident's care plan failed to include Enhanced Barrier Precautions (EBP) as ordered, despite the resident's medical conditions that warranted such precautions, including an indwelling catheter and a skin condition. The order for EBP was active, yet the care plan did not reflect this requirement, which was crucial for preventing infection and ensuring the resident's safety. Interviews with staff, including the DON, indicated that while there were informal methods to communicate EBP needs, such as stickers on resident names, the care plan itself did not provide the necessary guidance. The facility's policies on care planning and mechanical lift usage were not adequately followed, leading to these deficiencies. The interdisciplinary team was responsible for updating care plans to reflect residents' needs, but this was not done effectively. The lack of specific instructions in the care plans for both residents could result in inadequate care and increased risk of harm, as staff relied on incomplete or informal communication methods rather than comprehensive, documented care plans.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was adequately monitored and free from unnecessary drugs. Specifically, the facility did not monitor a resident for side effects or adverse reactions related to the use of Apixaban, an anticoagulant medication. The resident, a female with diagnoses including muscle weakness, hyperlipidemia, abnormalities of gait, and hypertension, was receiving Apixaban twice daily. However, there was no order for side effect monitoring of the medication, and the Medication Administration Record for November showed no monitoring for side effects was in place. Interviews with facility staff revealed a lack of awareness and adherence to the policy regarding monitoring for side effects of blood thinners. The Administrator admitted to not being familiar with the general risks associated with not monitoring blood thinner side effects, while the Director of Nursing stated that floor nurses should include side effect monitoring when receiving an order for a blood thinner. The facility's policy on Pharmacy Services, revised in January 2022, indicated that medication ordered without adequate monitoring is considered an unnecessary drug.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food was served at an appetizing temperature for a resident, leading to dissatisfaction and additional expenses for the resident. The resident, a female with multiple medical conditions including neuromyelitis optica, paraplegia, and legal blindness, reported that meals served in her room were often cold or lukewarm. Despite her requests for reheating, staff were reluctant or refused to accommodate her preferences, citing federal and state regulations as the reason. The resident noted that scrambled eggs and toast were frequently served at undesirable temperatures, impacting her ability to enjoy the meals. Interviews with the resident revealed that the issue persisted throughout her stay, although there was some improvement during the state surveyors' visit. The resident had to spend a significant amount of money on outside food due to the unsatisfactory quality and temperature of the facility's meals. An interview with an LVN indicated that the facility's procedure was to provide a new tray rather than reheating food, and that any reheating was to be done by kitchen staff during kitchen hours. The facility's policy required food to be served at a temperature above 135°F, but this standard was not consistently met for the resident.
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. For Resident #52, a CNA did not adhere to proper hand hygiene protocols while performing perineal care. The CNA failed to wash her hands or use an alcohol-based hand sanitizer between changing gloves from handling a soiled brief to applying a clean one. This lapse in protocol was acknowledged by the CNA, who admitted forgetting to wash her hands, and by the facility's administration, who confirmed the expectation for staff to follow infection control policies to prevent the spread of bacteria and potential infections. For Resident #82, the facility did not ensure that Enhanced Barrier Precautions (EBP) were properly communicated and implemented. There was no signage or indication outside the resident's room to alert staff and visitors of the need for EBP, nor was PPE readily accessible. The resident's room was observed to have a foul odor and multiple soiled towels, which the resident used to manage fluid leakage from his legs. The resident expressed a preference for managing his towels due to concerns about availability, which was not addressed in his care plan. The facility's Director of Nursing (DON) stated that EBP should be communicated through rounds and spot checks, but there was no consistent system in place to ensure PPE availability or proper signage. The facility's policies on infection prevention and control, including hand hygiene and transmission-based precautions, were not effectively implemented. The lack of proper environmental cleaning and disinfection in Resident #82's room, combined with the absence of clear communication and availability of PPE, posed a risk of cross-contamination and infection. The facility's failure to adhere to its own policies and procedures contributed to the deficiencies observed during the survey.
Failure to Maintain Dignified Environment Due to Laundry Neglect
Penalty
Summary
The facility failed to maintain a dignified environment for two residents by not ensuring their soiled personal clothing was taken to the laundry. Resident #2, a male with Alzheimer's Disease and Chronic Respiratory Failure, reported that his laundry had not been taken for eight days despite requesting assistance from nursing staff. His room had a strong odor of urine and body odors, with an overflowing laundry basket identified as the source. The resident expressed feelings of anger and neglect due to the situation. Similarly, Resident #3, a male with heart failure, experienced a similar issue with his laundry not being taken to the laundry room. He reported that he had asked staff to take his clothes but was told it was not their responsibility. The resident expressed feelings of sadness, loneliness, and neglect, and refrained from having his grandchildren visit due to the odor in his room. Observations confirmed the presence of strong odors and a full laundry basket in his room. Interviews with various staff members, including CNAs, LVNs, and the Director of Nursing, revealed confusion and miscommunication regarding the responsibility for laundry collection. While the facility's policies indicated that CNAs were responsible for collecting and transporting dirty laundry, some staff members were unaware of this duty. The facility's administration expected CNAs to follow the schedule and ensure a homelike environment, but the issue of dirty laundry buildup was not previously observed by the administration.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents, as observed during a survey. Resident #2, a male with Alzheimer's Disease and Chronic Respiratory Failure, reported that his soiled personal clothing had not been taken to the laundry for eight days, despite requesting assistance from nursing staff. The resident's room had a strong odor of urine and body odors, with a laundry basket overflowing with dirty clothing, which was identified as the source of the odor. The resident expressed feelings of anger and neglect due to the situation. Similarly, Resident #3, a male diagnosed with Heart Failure and in need of personal care, experienced a similar issue with his laundry not being taken to the laundry room. The resident's room also had strong odors of urine and body odors, with a basket of dirty clothes filled to the top. The resident expressed feelings of sadness, loneliness, and neglect, and mentioned that he avoided having his grandchildren visit due to the unpleasant smell in his room. Interviews with various staff members, including CNAs, LVNs, and the Director of Nursing, revealed a lack of clarity and communication regarding the responsibility for collecting and transporting residents' dirty laundry to the laundry room. While the facility's policies indicated that CNAs were responsible for this task, there was confusion among staff, with some believing it was the responsibility of laundry personnel. This lack of adherence to established procedures contributed to the deficiency in maintaining a clean and homelike environment for the residents.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medication to a resident, leading to a medication error. The resident, a woman diagnosed with restless leg syndrome, anxiety disorders, and COPD, was prescribed Requip, ropinirole HCI, 3 MG at bedtime. However, on one occasion, the resident was mistakenly administered three tablets of Requip, totaling 9 MG, instead of the prescribed single 3 MG tablet. This error was identified through a medication error report and confirmed by the CMA who administered the medication, acknowledging the mistake of misreading the order. Following the administration of the incorrect dosage, the resident experienced symptoms such as dizziness, weakness, and difficulty speaking, which led her to seek assistance from the nursing staff. Vital signs were monitored, and an ECG/EKG was performed, revealing a prolonged QT interval, although no immediate harm was noted. The resident expressed feeling scared and angry about the situation, and it took her several days to feel normal again. Despite the resident's reported symptoms, the facility's medical director and nursing staff did not observe any significant adverse reactions or changes in vital signs. Interviews with facility staff revealed that the medication error was attributed to the CMA misreading the order, and the CMA was subsequently educated on the error. The facility's policy required medication errors to be reported and addressed, but the administration did not consider this incident a significant medication error. The facility had procedures in place for medication administration, including multiple checks to prevent errors, but these were not effectively followed in this instance.
Failure to Monitor Resident During Meal Service
Penalty
Summary
The facility failed to assist and monitor a resident during meal service despite a hospice order stating that she should be assisted with meals and not left alone with food. The resident, who had Alzheimer's disease, heart failure, dysphasia, and required a mechanically altered diet, choked on her meal and was subsequently sent to the ER where she was diagnosed with aspiration pneumonia and remained hospitalized for several days. This incident occurred despite previous warnings and meetings with the family and hospice staff about the resident's need for assistance and the risk of choking. The resident's care plan and hospice orders clearly indicated that she required supervision while eating and should not be left alone with food. However, on multiple occasions, the resident was observed eating alone, and her meal trays included items that were not suitable for her condition, such as bread. The family had repeatedly expressed their concerns to the facility's staff, including the DON and ADM, but these concerns were not adequately addressed, leading to the resident's hospitalization. Interviews with the family and staff, as well as a review of the resident's medical records, revealed that the facility did not follow the prescribed care plan and hospice orders. The DON admitted to not being aware of the specific orders for assistance with meals, and there were lapses in communication and verification of meal trays. This failure to provide adequate supervision and follow dietary restrictions placed the resident at significant risk and resulted in a serious health incident.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan for a resident who required supervision or touching assistance while eating was incomplete. This deficiency was identified during a review of the resident's records and interviews with staff members, revealing inconsistencies in the documentation and understanding of the resident's needs for assistance during meals. The resident, a [AGE] year-old male with diagnoses including hypertensive emergency, muscle weakness, hyperlipidemia, and hypothyroidism, was assessed to require supervision or touching assistance while eating. However, the care plan did not reflect this need accurately. Staff members provided conflicting information about the resident's need for assistance, with some stating that the resident did not require supervision while others acknowledged the need for assistance. Observations confirmed that the resident was left to eat without the necessary assistance, struggling to cut food and expressing a need for help. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the resident was on a high-risk list for nutrition and hydration and required staff assistance during meals. Despite this, the care plan and care profile were not updated to reflect the resident's needs accurately. The DON and ADON acknowledged the importance of updating care plans to ensure staff are aware of and can meet residents' needs, but this was not done in this case, leading to the identified deficiency.
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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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