Memorial City Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 1341 Blalock, Houston, Texas 77055
- CMS Provider Number
- 676258
- Inspections on file
- 34
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Memorial City Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Resident’s cellphone was taken to stop 911 calls. An LVN removed the resident’s phone and kept it at the nurse’s station after the resident repeatedly called 911 and complained of pain. The resident was cognitively intact, had lupus, epilepsy, anxiety, and significant ADL dependence. The roommate reported the resident was crying, using the call light, and calling for help when the phone was taken, and the resident later said she felt anxious, horrible, and mistreated.
A resident with lupus and chronic pain repeatedly pressed her call light, cried out in pain, called 911 twice, and pulled the fire alarm while asking to go to the hospital. The record showed required pain checks were not documented on consecutive days, and staff interviews indicated the resident’s distress was treated as behavior rather than as pain needing prompt assessment and response.
Failure to Offer COVID-19 Vaccine to Residents: The facility did not offer the COVID-19 vaccine to residents because staff believed repeated refusals meant it no longer needed to be offered. The ICPN, DON, MD, and administrator each stated they were unaware residents should still be offered the vaccine and allowed to accept or refuse it. The facility policy required residents and staff to be offered the vaccine, screened for contraindications, and educated before it was offered.
A resident with severe cognitive impairment, muscle weakness, a CVA history, and dependence for multiple ADLs was observed lying in bed with his call light placed on the head of the bed and out of reach. He stated he could not reach it and that it was out of reach most of the time. CNA and RN staff were unaware how it was placed there, and the DON stated call lights were to always be within reach.
Incomplete Transfer and Discharge Notice: A resident with severe cognitive impairment, fractures, pain, and discharge-planning difficulties received a discharge notice for nonpayment that listed an out-of-state address but did not identify a confirmed safe discharge location. The notice also omitted the Ombudsman's name and email address, and staff interviews showed the facility had not verified the discharge destination or provided the notice to the Ombudsman's office.
A resident with dementia, cognitive impairment, and multiple pain-related diagnoses was transferred to the hospital after a cough and family request, but the facility did not properly update and retransmit the MDS discharge information when the anticipated return did not result in readmission. The MDS Nurse said the discharge MDS was completed, but the care plan remained open because the discharge was not manually changed from anticipated return to returned not anticipated, and the quarterly/annual MDS later showed as overdue.
Expired Insulin Pens Kept in Medication Cart: Two residents with orders for insulin glargine had opened insulin pens kept in the med cart beyond the 28-day limit. An RN stated she should have checked the opening dates before each administration and discarded the pens after 28 days, while the DON said nurses were expected to check insulin pen dates before each administration.
Three residents who were dependent on staff for bathing and personal hygiene did not receive scheduled showers or bed baths as required by their care plans, with no documentation of refusals in the EMR or progress notes. Residents reported not being offered baths, and staff interviews confirmed complaints about missed care. The facility's policy required documentation of care and refusals, but this was not consistently followed.
A resident with severe cognitive and mobility deficits was found in bed without access to a call light, which had been placed on the floor and reportedly removed by staff due to frequent use. Staff interviews confirmed the expectation that call lights remain within reach, but there was no specific facility policy in place.
The facility failed to maintain a safe and clean environment for residents, with issues such as damaged and unclean walls, a loose headboard, and improperly stored personal care items. Staff interviews revealed a lack of communication and follow-up on maintenance and housekeeping issues, impacting residents' well-being and infection control.
The facility failed to provide appropriate respiratory care and equipment storage for several residents, leading to deficiencies. A resident received oxygen at a higher rate than prescribed, and multiple residents had respiratory equipment improperly stored, increasing infection risk. Staff did not consistently follow procedures for storing and labeling equipment, and the facility's policy lacked specific requirements, contributing to the oversight.
A facility failed to maintain proper infection control during tracheostomy care for a resident with severe cognitive impairment and multiple medical conditions. RN A and LVN B did not dispose of used materials in a biohazard bag, instead placing them in a clear trash bag and a linen container. Both staff members acknowledged the correct procedure but did not follow it, potentially leading to infection control issues.
The facility failed to maintain an effective pest control program, leading to the presence of pests in resident rooms. A live roach was found on a resident's bed during medication administration, and a spider was observed on the wall near another resident's bed. Staff reported these incidents, but pest control records showed no recent concerns, despite some ant activity and flies being noted. The facility's housekeeping policy requires a clean environment, but the presence of pests indicates a lapse in this standard.
A shower room was found with soiled towels, used personal care containers, gloves, hair, and dirty floors with stains and debris. Staff interviews revealed unclear procedures and inconsistent communication regarding cleaning responsibilities between CNAs, nursing, and housekeeping. Facility policies required a clean and sanitary environment, but these were not followed, resulting in an unclean and uncomfortable shower room for residents.
A resident with multiple chronic conditions received ongoing anticoagulant medication monitoring for aspirin administration without an active physician order for anticoagulant therapy. Documentation and interviews revealed confusion regarding the purpose of aspirin and a lack of clear, accurate medical records, resulting in monitoring that was not supported by current physician orders.
A resident with Alzheimer's disease who required assistance with mobility developed an unstageable pressure ulcer to the buttocks due to the facility's failure to implement and document required pressure ulcer prevention measures, such as frequent turning and repositioning. Staff interviews and record reviews confirmed that care plan interventions were not consistently followed, and there was no system in place to ensure compliance with pressure injury prevention protocols.
A resident with severe cognitive impairment and high fall risk experienced multiple falls without updates to their care plan. The facility failed to ensure the resident's bed was in the lowest position and did not implement new interventions after falls, leading to injuries. Staff interviews revealed confusion about care plan responsibilities after the MDS nurse quit, contributing to the deficiency.
A resident with severe cognitive impairment and on anticoagulant therapy experienced multiple falls due to inadequate supervision and failure to update the care plan with necessary interventions. Despite being a known fall risk, the resident's care plan was not revised after falls, and staff were unaware of the necessary interventions. Observations revealed environmental hazards, such as the absence of a fall mat and an unreachable call light, contributing to the resident's risk of harm.
A resident's bathroom in the facility was found to be in an unsanitary and unsafe condition, with a leaking toilet base and a strong odor of urine. Despite the resident's report of the issue persisting for months, staff interviews revealed a lack of timely action to address the problem. The resident's care plan emphasized the need for a safe environment due to fall risks, yet the bathroom's condition was neglected, posing a potential hazard.
The facility failed to maintain an effective pest control program, with numerous gnats observed in resident rooms and a live roach at the nurses' station in the 300 hall area. Residents expressed discomfort due to the persistent presence of gnats, and a roach was found near unsealed snacks. Staff interviews revealed a lack of a specific pest control policy, despite claims of proactive management.
The facility failed to respond to call lights in a timely manner, affecting four residents with various medical conditions. One resident was found in an unclean room with feces on the floor, while another experienced delays in call light responses, taking over 30 minutes. Two other residents reported dissatisfaction with nursing services due to delayed responses, with one stating the night shift did not respond at all. These issues were supported by grievances filed by other residents, indicating a systemic problem within the facility.
The facility failed to respond to call lights in a timely manner, affecting several residents with various medical conditions. One resident was found in an unclean environment due to unaddressed call lights, while others reported waiting over 30 minutes to an hour for assistance. Despite attempts by the DON to address the issue, persistent complaints and grievances indicate ongoing neglect in providing prompt care.
The facility failed to maintain an effective pest control program, resulting in a persistent roach infestation in residents' rooms, nursing stations, and common areas. Despite multiple treatments from February to July 2024, roach activity continued, with staff and residents reporting sightings. The maintenance supervisor admitted to being unaware of the pest control policy, and the DON acknowledged the ongoing issue. The facility's pest control efforts were inconsistent, failing to adhere to the policy requiring monthly servicing and prompt response to pest issues.
A resident with a history of cerebral infarction and dementia experienced respiratory distress, but the LTC facility failed to provide timely care. Despite being unresponsive and having low oxygen saturation, immediate interventions were not initiated. The NP's attempts to provide care were hindered by a malfunctioning suction machine, and emergency services were delayed. The resident was later declared brain dead and expired after support was removed.
Resident’s cellphone was taken to stop 911 calls
Penalty
Summary
The facility failed to ensure a resident remained free from abuse when an LVN removed the resident’s cellphone and kept it at the nurse’s station as a way to stop the resident from calling 911. The resident was cognitively intact with a BIMS score of 15 and had diagnoses including lupus, epilepsy, anxiety disorder, obesity, pain in unspecified joints, stiffness, muscle wasting and atrophy, cognitive communication deficit, and need for assistance with personal care. The resident was dependent for multiple ADLs, including toileting, bathing, dressing, footwear, and personal hygiene, and was always incontinent of bowel and bladder. The record showed that the resident had called 911 multiple times during the night and had also attempted to pull the fire alarm. The LVN stated that after the resident passed her a cellphone and 911 was on the line, she told the operator the resident was fine and hung up. She later stated that, as an intervention to prevent further 911 calls, she and a CNA got the resident out of bed and she took the resident’s cellphone to the nurse’s station. She acknowledged she did this to prevent the resident from making additional 911 calls and said she thought she was doing the right thing. The resident’s roommate stated the resident had been crying, pressing the call light, and calling the front desk from her cellphone for help, and that the LVN took the phone from the resident while 911 was still on the line. The resident later stated that when staff took her phone to prevent her from calling 911 and would not address her pain, she felt anxious, horrible, and mistreated. The MD stated she would not expect staff to take a resident’s phone as an intervention to avoid 911 calls, and the DON stated taking a resident’s cellphone could be considered abuse and could hinder the resident’s ability to call 911.
Failure to Address Resident Pain and Requests for Help
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with lupus, epilepsy, anxiety, obesity, joint pain, stiffness, muscle wasting and atrophy, and cognitive communication deficit. The resident’s care plan identified her as at risk for pain and discomfort related to lupus, and she had standing and newly added pain-related orders, including scheduled acetaminophen-codeine and gabapentin, along with an order for a lumbar spine x-ray after she reported pain. On 03/04/2026, the resident repeatedly sought help during the early morning hours. The report states she pressed her call light, cried out in pain, called 911 twice, and pulled the fire alarm while requesting to go to the hospital. A roommate stated the resident woke up crying in pain around 4:00 a.m., called the facility front desk from her cellphone, and called 911 again after staff responded. The roommate also stated the resident continued yelling for assistance until about 5:00 a.m., when staff got her out of bed and into a wheelchair, and later returned her to bed after the fire alarm was activated. The resident’s record showed pain monitoring was required every shift using a 0-10 scale, but no pain levels were recorded on 03/03/2026 or 03/04/2026. The record also showed that after the resident reported pain, a nurse completed a pain evaluation and medication was administered, and later that day the MD documented severe, sharp pain that was worse than usual and ordered additional pain treatment and imaging. Staff interviews reflected that the resident’s calls to 911 were treated as behavior rather than as pain-related distress, and one nurse stated she told 911 the resident was fine and removed the resident’s cellphone. The report states the facility failed to monitor and address the resident’s pain during the period when she was repeatedly seeking help and requesting hospital transfer.
Failure to Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure each resident was offered the COVID-19 vaccine unless the immunization was medically contraindicated or the resident had already been immunized. During interviews, the ICPN stated the facility did not offer COVID vaccines to residents because residents and their representatives always declined the vaccination, so the facility stopped offering it. She stated she was unaware the facility should have continued to offer the vaccine and allow residents to accept or refuse it, and she did not recall when the facility stopped offering it. The DON, MD, and administrator each stated they were unaware the facility should have offered the COVID vaccine to residents and allow them to accept or refuse it, and each did not recall when the facility stopped offering the vaccine. Record review of the facility’s Infection Control Policy dated 05/13/2023 showed residents and staff were to be offered the COVID-19 vaccine when supplies were available, screened for prior immunization and contraindications, and given education about the vaccine before it was offered. CDC ACIP recommendations dated October 2024 stated adults aged 65 years and older should receive 2 doses of the 2024-2025 COVID-19 vaccine, and CDC COVID recommendations dated 11/19/2025 stated the vaccine helps protect against severe illness, hospitalization, and death and is especially important for persons ages 65 and older.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure Resident #38’s call light was within reach while he was lying in bed. Resident #38 was a male admitted to the facility with diagnoses including cerebral infarction, muscle weakness, and a history of falling. His admission MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and he was dependent on staff for personal hygiene, toileting hygiene, showering, upper body dressing, and lower body dressing. He was also always incontinent of bladder and bowel and used a wheelchair for mobility. His care plan identified an ADL self-care performance deficit related to cerebral infarction and noted he was at risk for falls related to cerebral infarction and muscle weakness. A progress note stated the resident’s bed was to be in the lowest position and the call light within reach. However, during observation, the resident was found lying in bed with the call light placed on the head of the bed and out of reach. The resident stated he could not reach it and said it was out of his reach most of the time. CNA Q stated he was unaware how the call light was placed out of reach and said he checked call light placement every morning and whenever he went to residents’ rooms. RN Q stated she was unaware why the call light was not within reach and said she checked call lights when providing care. The DON stated residents’ call lights were to always be within reach and that staff were expected to round every 2 hours and ensure call lights were within reach.
Incomplete Transfer and Discharge Notice
Penalty
Summary
The facility failed to ensure that the written notice of transfer or discharge for a resident contained all federally required elements. The notice for the resident, who had severe cognitive impairment with a BIMS score of 00 and a history of fractures, radial nerve injury, chronic pain, and difficulty with discharge planning, did not include a safe discharge location. The notice also did not contain the Ombudsman's name and email address. The resident had been admitted after a fall with multiple fractures and had ongoing issues with pain, mobility limitations, and refusal of some assessments and services. Progress notes reflected repeated discharge planning discussions, concerns about nonpayment, and the resident's refusal to provide financial information or cooperate with placement planning. The facility issued a 30-day discharge notice for nonpayment and listed an out-of-state address as the discharge location, but later interviews showed the facility had not contacted anyone at that address and could not confirm that it was a safe discharge location. During interviews, facility staff stated the resident had not provided enough information to identify a safe discharge plan and that the discharge notice lacked the Ombudsman information. The Ombudsman also stated the facility had not provided her office with a copy of the discharge notice. The facility's policy required the notice to include the specific reason for discharge, effective date, discharge location, appeal rights, appeal assistance information, and the Ombudsman's contact information, but the notice reviewed by surveyors did not contain all of those required elements.
MDS Discharge Assessment Not Properly Updated After Hospital Transfer
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete MDS data to the CMS system for one closed record, CR #154. CR #154 was admitted with diagnoses including right shoulder pain, unspecified fall, pain in unspecified joint, muscle wasting and atrophy of multiple sites, cognitive communication deficit, need for assistance with personal care, and dementia with no behavioral, psychotic, mood, or anxiety disturbance. A comprehensive MDS reflected a BIMS score of 08, indicating moderate impaired cognition. The discharge MDS reflected an unplanned discharge with anticipated return due to a short-term hospital transfer. CR #154 developed a cough on 01/20/2026, and the change-of-condition form documented that family wanted the resident sent to the hospital. The NP was notified and orders were given for a stat CXR, guaifenesin, and DuoNeb PRN. Progress notes show the family requested hospital transfer related to the cough, the DON was informed, and CR #154 was transported by EMS to the hospital on 01/23/2026. Additional notes reflected ongoing discussion with family about Medicare coverage and financial responsibility, and the facility admission, transfer, discharge log showed the resident discharged on 01/23/2026. On review of the record on 04/23/2026, CR #154's quarterly/annual MDS was 77 days overdue. During interview, the MDS Nurse stated she was responsible for transmitting MDS discharges and said the discharge MDS had been completed on 01/23/2026, but the care plan was not closed because the resident did not return within 30 days and the system did not generate the expected notification. RRN A stated that when a resident discharges with anticipated return and does not readmit, the facility must manually complete a discharge deletion so the care plan closes and no further MDS tasks trigger, and he stated the discharge was not manually changed from anticipated return to returned not anticipated. The facility policy stated that a significant correction assessment must be completed no later than the 14th calendar day after determination that a significant error occurred and that a Part A PPS discharge assessment must be completed within 14 days after the end date of the most recent Medicare stay.
Expired Insulin Pens Kept in Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when it did not ensure that opened insulin glargine pens were dated and discarded within 28 days of opening for Resident #30 and Resident #41. Resident #30 had an active order dated 04/09/2026 for insulin glargine 100 units/ml multiple-dose pen, 20 units SQ daily for diabetes. Resident #41 had an active order dated 03/11/2026 for insulin glargine 100 units/ml multiple-dose pen, 30 units SQ daily for diabetes. During an observation of Hall 100's medication cart on 04/24/2026 at 12:08 p.m., staff were found to have opened and dated two insulin glargine 100 units/ml multiple-dose pens for Resident #30 and Resident #41 and kept them in the medication cart beyond 28 days from the opening date. Both pens had been opened and dated on 03/23/2026. RN Q stated she should have checked the opening dates before each administration and discarded the pens after 28 days of opening, and said she was unaware the pens were expired. The DON stated she expected nurses to check insulin pen opening dates before each administration and discard them after 28 days, and that she spot checked insulin pens for expiration dates weekly.
Failure to Provide Scheduled Bathing and Hygiene Services to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain grooming and personal hygiene. Specifically, three residents who required substantial or total assistance with bathing did not receive scheduled showers or bed baths on multiple occasions, as documented in their care plans and electronic medical records (EMR). The missed care was not attributed to resident refusals, as there was no documentation of refusals in the progress notes or EMR for these residents, and interviews with the residents confirmed they had not refused care. One resident, a female with a history of pelvic fracture, anemia, and left upper limb nerve lesion, was bedbound and required maximal assistance for bathing. She was frequently incontinent and her care plan specified scheduled bathing three times per week. However, records showed she received only one bath and one documented refusal over a month, missing numerous scheduled baths. She reported to surveyors that staff did not offer her baths and were rude when she requested them. Another resident, a male with heart failure, COPD, quadriplegia, and other chronic conditions, was dependent on staff for all bathing and was always incontinent. His records showed no data for bathing tasks and only two refusals documented in progress notes, despite missing all scheduled baths during the review period. He also reported not receiving scheduled showers and that staff told him they were too busy. A third resident, a female with multiple sclerosis, osteoarthritis, and an indwelling catheter, was dependent on staff for all personal hygiene and had a stage 4 pressure ulcer. Her records indicated only one bed bath documented in the EMR and no refusals, despite missing all other scheduled baths. She stated she received maybe two baths a week and could not recall her last bath. Staff interviews revealed inconsistent knowledge of which residents refused care, and several staff members acknowledged receiving complaints from residents about not getting showers or baths. The facility's policy required documentation of care and refusals in the EMR, but this was not consistently done for the affected residents.
Failure to Ensure Resident Access to Call Light in Bed
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical diagnoses, including vascular dementia, Alzheimer's disease, and mobility deficits, did not have access to a functioning call light while in bed. Observation revealed the call light was on the floor, out of the resident's reach, and the resident reported that staff had removed it from her room because she used it too frequently. The resident's care plan specifically required that the call light be within reach due to her risk for falls and need for staff assistance with activities of daily living. Interviews with staff confirmed that all personnel were responsible for ensuring call lights were accessible to residents, and that call lights should not be left on the floor. The nurse on duty acknowledged the importance of call light accessibility, especially for residents with confusion and mobility issues. The Director of Nursing stated that monthly in-services were conducted on call light procedures, but also confirmed that the facility did not have a specific written call light policy.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as observed during a survey. In the rooms of three residents, there were issues with damaged and unclean walls. One resident's room had missing paint, another had a hole in the wall with a TV plug hanging out and dirty walls, and a third had chipped paint along the baseboard. Additionally, a resident's headboard was loose and moving, and there were brown stains and a hole with exposed wiring on the walls. These conditions were not reported or addressed in a timely manner, as evidenced by interviews with staff who were unaware of the issues. The facility also failed to properly label and store personal care items for a resident, which is necessary for infection control. A wash basin was found on a nightstand and another in the bathroom, both unlabeled and not bagged. The CNA responsible for the resident acknowledged the importance of labeling and bagging personal care items to prevent cross-contamination but did not ensure it was done. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Housekeeping Supervisor, and Maintenance Director revealed a lack of communication and follow-up on maintenance and housekeeping issues. The DON stated that staff were supposed to report environmental issues to maintenance, but the Maintenance Director was unaware of the problems in the resident's room. The Housekeeping Supervisor noted that rooms should be cleaned daily, but the walls in one resident's room were not cleaned as required. The ADON and CNA also expressed concerns about the impact of these deficiencies on residents' well-being and infection risk.
Inadequate Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, leading to deficiencies in the care provided. Resident #14 was observed receiving oxygen at 8L/min, contrary to the physician's order of 6L/min. This discrepancy was noticed by LVN A, who confirmed the correct order with LVN B and adjusted the oxygen level accordingly. Despite the adjustment, the initial oversight placed the resident at risk of receiving inappropriate oxygen levels. Multiple residents, including Residents #21, #11, #17, #43, and #86, were found to have respiratory equipment improperly stored, increasing the risk of respiratory infections. Resident #21's nebulizer machine was found on the floor, and the tubing was not stored properly. Similarly, Resident #11's nebulizer tubing and mask were not dated or stored in a plastic bag, and Resident #17's oxygen tubing was left on the floor. Resident #43 and Resident #86 also had oxygen tubing on the floor, which was not stored in a clean and sanitary location. The facility's failure to adhere to professional standards of practice and the residents' care plans resulted in inadequate respiratory care. The observations and interviews revealed that the staff did not consistently follow procedures for storing and labeling respiratory equipment, which is crucial for infection control. The DON acknowledged the importance of proper storage and labeling but noted that the facility's policy did not specify these requirements, contributing to the oversight.
Improper Disposal of Biohazard Materials During Tracheostomy Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper disposal of biohazard materials during tracheostomy care for a resident. During an observation, RN A and LVN B completed tracheostomy suctioning for a resident but failed to dispose of used materials, including gauze, gloves, and a tracheostomy inner tube with bodily fluids, in a biohazard bag. Instead, these materials were placed in a clear trash bag and then in a container used for linen, which is not the correct procedure for handling biohazardous waste. The resident involved was a male with severe cognitive impairment and multiple medical conditions, including anoxic brain damage, tracheostomy status, and pneumonia. Interviews with LVN B and RN A revealed that they were aware of the proper procedure for disposing of biohazard materials but did not follow it. LVN B acknowledged that the failure to use a biohazard bag could lead to infection control issues, while RN A admitted that the materials should have been double-bagged and placed in a biohazard bag before being taken to the soiled utility room. The facility's Equipment Protocol policy requires potentially contaminated items to be placed in an impervious clear plastic bag labeled as contaminated and processed accordingly.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in resident rooms. During a medication pass, a live roach was observed crawling on the side of a resident's bed, and a Licensed Vocational Nurse (LVN) had to brush it away with a face towel while administering medication through a gastric tube. In another instance, a spider was found on the wall near a resident's bed, and a Certified Nursing Assistant (CNA) had to remove it using a towel. The CNA mentioned that pest sightings are reported in the facility's computer system and noted that pests tend to appear when it rains. Interviews with the Director of Nursing (DON) and the Maintenance Director revealed that they were aware of the pest issues, but no recent concerns had been reported by pest control. The Maintenance Director mentioned that work orders, including those for pest control, are checked daily, and ambassadors are responsible for reporting environmental issues. A review of the facility's pest control records showed visits by pest control on three occasions, with no sightings of roaches or spiders, but some ant activity and flies were noted. The facility's housekeeping policy emphasizes maintaining a clean and orderly environment, yet the presence of pests indicates a lapse in this standard.
Failure to Maintain Clean and Safe Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in one of the two shower rooms on Hall 400. During an observation, the shower room was found with large soiled towels on the floor, used empty containers of personal care items on wood shelving, gloves on the floor, and a ball of white hair. The floor was dirty with brown and black stains, and there was debris behind the shelving. These conditions were directly observed by a CNA, who acknowledged the uncleanliness and began cleaning the room during the survey. Interviews with staff revealed confusion and inconsistency regarding responsibility and procedures for cleaning the shower room. The CNA stated that CNAs were not supposed to leave items behind and that both nursing staff and housekeeping were responsible for cleanliness. However, the communication process for requesting cleaning was unclear, with references to a missing communication book and possible computer-based communication that could not be demonstrated. Housekeeping staff confirmed that the shower room should be cleaned at least daily and as needed, but acknowledged that the room had not been cleaned the previous day. The Environmental Service Department also stated that cleaning between uses was important for infection control, but the room had not yet been cleaned on the day of observation. Review of facility policies indicated requirements for maintaining a safe, sanitary, and comfortable environment, with specific mention of infection prevention and control, general housekeeping, and resident rights to clean conditions. Despite these policies, the observed state of the shower room and staff interviews demonstrated a failure to adhere to established procedures, resulting in an unclean and uncomfortable environment for residents using the shower room.
Failure to Maintain Accurate Physician Orders for Anticoagulant Monitoring
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not having a current physician order for anticoagulant medication, despite ongoing monitoring for anticoagulant effects. Record review showed that the resident, an elderly female with multiple diagnoses including muscle wasting, COPD, dementia, hypertension, chronic pain, and polyosteoarthritis, had orders for anticoagulant monitoring tied to aspirin administration. However, there was no active physician order for an anticoagulant medication at the time the monitoring was being performed. Documentation indicated that the resident received anticoagulant monitoring every twelve hours for aspirin, with changes in dosage and discontinuation dates, but without a corresponding active order for anticoagulant therapy. Interviews with the DON revealed confusion regarding the purpose of aspirin therapy and the rationale for continued monitoring, as well as a lack of clarity in documentation. The facility's medication administration policy requires medications to be administered as ordered by the physician and in accordance with professional standards, which was not followed in this case.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
A resident with Alzheimer's disease, who required assistance with activities of daily living and was at risk for pressure ulcers, developed an unstageable pressure ulcer to the bilateral buttock while under the facility's care. The resident's care plan included interventions such as frequent turning and repositioning, as well as weekly skin checks, but there was no documentation that these interventions were consistently implemented. Skin assessments completed prior to the incident did not indicate any skin breakdown, and there was no documentation of turning and repositioning in the clinical record. Staff interviews revealed that the resident had not been getting out of bed for several days prior to hospital transfer, and CNAs were unable to confirm how often the resident was turned or repositioned. The wound care nurse and other staff acknowledged that the wound was acquired at the facility and could have been prevented with proper repositioning. The Director of Nursing (DON) admitted there was no system in place to monitor whether the resident was being turned as required by facility policy, and that this failure placed residents at risk for skin breakdown and pressure injuries. Upon discovery of the wound, the resident was found to have an open area with dark discoloration and drainage, and was subsequently transferred to the hospital, where the wound was assessed as unstageable. The family and hospital staff confirmed the presence of the wound and the resident's critical condition upon admission. The facility's failure to implement and document pressure ulcer prevention interventions, as outlined in the care plan and facility policy, directly contributed to the development of the unstageable pressure ulcer.
Failure to Update Care Plan After Resident Falls
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, mental, and psychosocial needs. Specifically, the facility did not ensure that the resident's bed was in the lowest position as per the care plan while the resident was in bed. Additionally, the facility did not update the resident's care plan with new interventions after the resident experienced three falls, which placed the resident and other fall-risk residents at risk of serious harm and injury. The resident involved was a male with Fragile X syndrome, muscle weakness, unspecified falls, lack of coordination, and cognitive communication deficit. He had a BIMS score of 0, indicating severe cognitive impairment, and required total assistance for sit-to-stand and bed transfers. Despite being at high risk for falls, as indicated by multiple fall risk evaluations, the facility did not update the resident's care plan with new interventions following his falls, which included injuries such as a hematoma and skin tears. Interviews with facility staff revealed a lack of communication and responsibility regarding updating the resident's care plan. The MDS nurse responsible for the resident's care plan had recently quit, and there was confusion among staff about who should update the care plan. Despite discussions in morning meetings about the resident's falls, the care plan was not updated, and staff were not informed of new interventions. This lack of action and communication contributed to the deficiency identified by surveyors.
Removal Plan
- Resident #1 was reassessed by Director of Nursing head to toe for injury and pain. The MD was notified of the findings with no new orders received.
- Resident #1 was reassessed by the Director of Nursing and/ or designee related to use of Plavix and potential side effects, as well as falls, fall risk and fall interventions with no concerns noted. The MD was notified with no new orders were received.
- The IDT reviewed Resident #1's plan of care related falls, injuries, pain and use medication Plavix. The plan of care was updated to reflect interventions regarding falls, injuries, pain and pharmacy consult medication as indicated and the RP was notified.
- The Director of Nursing and/ or designee reassessed residents who sustained falls head to toe for pain and injury with no new concerns.
- The Director of Nursing and/ or designee reviewed the status of resident injuries sustained from falls with no concerns for appropriate treatment, care plan interventions and resolutions.
- The Director of Nursing and/ or designee reviewed the fall risk assessments for current residents for timely completion where indicated fall risk was reassessed and updated.
- The IDT reviewed the falls care plans for residents identified to be at high risk for falls and/ or residents with physician orders for an anticoagulant for appropriate interventions and implementation. There were updates completed as indicated.
- The Director of Nursing and/ or designee reviewed the progress notes to ensure resident falls and/ or changes in condition related to falls were identified and addressed. There were no concerns noted.
- The Director of Nursing and/or designee educated staff on updated care plans. Care Plans and/or interventions will be updated by the nursing staff at the time of occurrence. Care Plan policy was reviewed and there were no updates. The Kardex and tasks will be updated to ensure DCS are aware of interventions placed in the care plans. Nursing staff were reeducated on reviewing the Kardex and task for updated interventions.
- The Director of Nursing and/ or designee reviewed the care plans for current residents who sustained falls for implementation of interventions to address the fall. Where applicable the care plans were modified for individualization.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on fall prevention and the Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls.
- The Regional Clinical Specialist reeducated the Director of Nursing on the Incident and Accident Policy.
- The Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. Resident changes in condition to include new and/ or repeat falls, changes in cognition and/ or gait and ADL status.
- The Director of Nursing and/ or designee began reeducation for the IDT (Administrator, Licensed Nurses, Social Work, Care Management Nurses, Activities Director, Director of Rehab, Dietary Manager) on the policy for comprehensive care plans. Re-education included timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions.
- The Director of Nursing and/ or designee began reeducation with 100% of Licensed Nurses on the Incident and Accident policy to include: Accident and Incident report completion and documentation requirements e.g. immediate actions/ interventions to prevent a fall and supervise residents. Resident fall risk and fall risk reassessment, fall interventions and timeliness, resident supervision related to falls, as well as risk for injury from falls related to use of anticoagulant medication. Resident monitoring and PN documentation post fall (minimum of 72 hours). Changes in condition, to include notifications, interventions, documentation, monitoring and follow-up. Completion of resident skin evaluations, wound assessment forms, pain assessments, treatment orders, monitoring and care plans.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, DON and/or designee prior to the start of their next scheduled shift.
- The Director of Nursing/ designee will review the 24-hour report for any changes in condition related to new falls or risk for falls. Ensure the physician is notified timely and that actions are taken timely to address the change in condition, actual fall and/ or fall risk.
- An Ad Hoc QAPI was conducted attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 656- Develop/Implement Comprehensive Care Plan.
- The Director of Nursing will monitor the following daily for 30 days, then three times weekly for two months. Changes in condition, to include resident falls. DON will ensure falls are promptly addressed by reviewing the 24-hour report and residents clinical records during the Morning Clinical Meeting Accident and Incidents for completion, immediate interventions and care planning, completion of assessments and notifications. Resident falls and anticoagulant medication are care planned for new falls and new orders for anticoagulants. Skin evals, wounds assessments forms and orders for injuries resulting from Incidents and Accidents.
Inadequate Supervision and Care Plan Updates for Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions for a resident who was a known fall risk and was prescribed an anticoagulant. This deficiency resulted in multiple falls, including incidents on 7/21/2024, 9/14/2024, and 9/15/2024, which led to injuries and hospitalization. The resident, who had severe cognitive impairment and required total assistance for mobility, was not adequately monitored, and his care plan was not updated following these falls. The resident's care plan, which should have included specific interventions to prevent falls, was not revised after the incidents. Despite being identified as high risk for falls, the care plan lacked updated interventions to address the resident's behavior of leaning forward in his wheelchair and pulling up on handrails. Interviews with facility staff revealed a lack of communication and responsibility regarding the updating of care plans, with staff unaware of the resident's recent falls and the necessary interventions. Observations showed that the resident's environment was not adequately adjusted to prevent falls, such as the absence of a fall mat by the bed and the call light being out of reach. The facility's failure to update the care plan and implement effective fall prevention measures placed the resident at risk of serious harm, as evidenced by the repeated falls and injuries.
Removal Plan
- Resident #1 was reassessed by Director of Nursing head to toe for injury and pain. The MD was notified of findings with no new orders received.
- Resident #1 was reassessed by the Director of Nursing and/ or designee related to use of Plavix and potential side effects, as well as falls, fall risk and fall interventions with no concerns noted. The MD was notified with no new orders received.
- The IDT reviewed Resident #1's plan of care related falls, injuries, pain and use medication Plavix. The plan of care was updated to reflect interventions regarding falls, injuries, pain and pharmacy consult medication as indicated and the RP was notified.
- The Director of Nursing and/ or designee reassessed residents who sustained falls head to toe for pain and injury with no new concerns.
- The Director of Nursing and/ or designee reviewed the status of resident injuries sustained from falls with no concerns in the last 30 days for appropriate treatment, care plan interventions and resolutions.
- The Director of Nursing and/ or designee reviewed the fall risk assessments for current residents for timely completion where indicated fall risk was reassessed and updated.
- The IDT reviewed the falls care plans for resident identified to be at high risk for falls and/ or residents with physician orders for an anticoagulant for appropriate interventions and implementation. There were updates completed as indicated.
- The Director of Nursing and/ or designee reviewed the progress notes for the last 30 days to ensure resident falls and/ or changes in condition related to falls were identified and addressed. There were no concerns noted.
- The Director of Nursing and/or designee educated staff on updated care plans. Care Plans and/or interventions will be updated by the nursing staff at the time of occurrence. Care Plan policy was reviewed and there were no updates. The Kardex and tasks will be updated to ensure DCS are aware of interventions placed in the care plans. Nursing staff were reeducated on reviewing the Kardex and task for updated interventions.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on fall prevention and the Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls.
- The Regional Clinical Specialist reeducated the Director of Nursing on the Incident and Accident Policy.
- The Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. Resident changes in condition to include new and/ or repeat falls, changes in cognition and/ or gait and ADL status.
- The Director of Nursing and/ or designee began reeducation for the IDT (Administrator, Licensed Nurses, Social Work, Care Management Nurses, Activities Director, Director of Rehab, Dietary Manager) on resident care plans, timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions.
- The Director of Nursing and/ or designee began reeducation with 100% of Licensed Nurses on the Incident and Accident policy to include: Accident and Incident report completion and documentation requirements e.g. immediate actions/ interventions to prevent a fall and supervise residents. Resident fall risk and fall risk reassessment, fall interventions and timeliness, resident supervision related to falls, as well as risk for injury from falls related to use of anticoagulant medication. Resident monitoring and PN documentation post fall (minimum of 72 hours). Changes in condition, to include notifications, interventions, documentation, monitoring and follow-up. Completion of resident skin evaluations, wound assessment forms, pain assessments, treatment orders, monitoring and care plans.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, DON and/or designee prior to the start of their next scheduled shift.
- The Director of Nursing/ designee will review the 24-hour report for any changes in condition related to new falls or risk for falls. Ensure the physician is notified timely and that actions are taken timely to address the change in condition, actual fall and/ or fall risk.
- An Ad Hoc QAPI was conducted attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 689-Accidents/ Supervision.
- The Director of Nursing will monitor the following daily for 30 days, then three times weekly for two months. Changes in condition, to include resident falls. DON will ensure falls are promptly addressed by reviewing the 24-hour report and residents clinical records during the Morning Clinical Meeting. Accident and Incidents for completion, immediate interventions and care planning, completion of assessments and notifications. Resident falls and anticoagulant medication are care planned for new falls and new orders for anticoagulants. Skin evals, wounds assessments forms and orders for injuries resulting from Incidents and Accidents.
Failure to Maintain a Safe and Clean Environment for a Resident
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the condition of the resident's bathroom. The resident's toilet base was stained and dirty, and the toilet was in disrepair, with a liquid substance leaking from its base. The bathroom emitted a strong odor of urine, and the resident reported that the issue had persisted for months despite informing staff. The resident's care plan highlighted the need for a safe environment due to his risk of falls, yet the unsanitary and unsafe bathroom conditions were not addressed. Interviews with facility staff revealed a lack of awareness and action regarding the resident's bathroom condition. The Activity Director noted the toilet's dirtiness and submitted a maintenance request but did not observe the water on the floor. The DON acknowledged the missing ring around the toilet base, which contributed to the leak, and recognized the potential hazard for the resident, who occasionally stood up from his wheelchair. The Maintenance Director admitted to not having inspected the resident's room before and identified issues with the toilet's caulking and wax ring, which had deteriorated over time, leading to the unsanitary conditions.
Pest Control Deficiency in Resident Rooms and Nurses' Station
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous gnats and a live roach in the 300 hall area. Observations and interviews revealed that gnats were present in the rooms of four residents, causing discomfort and frustration. One resident expressed that the gnats were particularly bothersome as he spent most of his time in his room. Another resident mentioned that despite pest control spraying, the gnats persisted, making him uncomfortable in his living space. Additionally, a live roach was observed at the nurses' station, emerging from a pest control book, with snacks nearby that were not fully sealed. Interviews with facility staff, including the Maintenance Director and the Director of Nursing (DON), indicated that pests such as gnats and roaches were not acceptable in resident areas. The Maintenance Director acknowledged that roaches could access snacks left at the nurses' station, and the DON stated that staff should document pest sightings in the pest control binder. The facility administrator mentioned that the facility did not have a specific pest control policy but relied on the pest control company's program specifications. Despite claims of proactive pest management, the presence of pests in resident rooms and the nurses' station was noted, with pest control services reportedly conducted weekly.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity by not responding to call lights in a timely manner, affecting four residents. Resident #1, a female with hypertension, atrial fibrillation, and type 2 diabetes, was found in an unclean room with feces on the floor and a full commode. Her representative reported that the resident's call light was not answered, leading to an accident when she attempted to use the commode by herself. Resident #2, a male with rhabdomyolysis, acute kidney failure, and hypothyroidism, also experienced delays in call light responses, with reports indicating it took over 30 minutes for staff to respond. Resident #3, a male with type 2 diabetes, hypertension, and poly-osteoarthritis, expressed dissatisfaction with the nursing service due to the delayed response to call lights, which often went unanswered for over 30 minutes. Resident #4, a male with epilepsy, Todd's paralysis, hypertension, and schizoaffective disorder, reported that the response time for call lights was about an hour, with no response from the night shift. These delays in responding to call lights were corroborated by grievances filed by other residents, indicating a systemic issue within the facility. The facility's policy on resident rights emphasizes the importance of dignity and respect, which was not upheld in these instances. Interviews with staff and residents revealed ongoing issues with call light response times, despite in-service training and attempts by the DON to address the problem. The facility's failure to respond promptly to call lights compromised the residents' quality of life and their ability to exercise their rights to self-determination and communication.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to treat residents with respect and dignity by not responding to call lights in a timely manner, affecting four residents. Resident #1, a female with hypertension, atrial fibrillation, and type 2 diabetes, was found in an unclean environment with feces on the floor and a full commode. Her representative reported that the call light was not answered, leading to an accident when the resident attempted to use the commode by herself. Resident #2, a male with rhabdomyolysis, acute kidney failure, and hypothyroidism, also experienced delayed responses to call lights, with reports indicating it took over 30 minutes for staff to respond. Resident #3, a male with type 2 diabetes, hypertension, and poly-osteoarthritis, expressed dissatisfaction with the nursing service due to the delayed response to call lights, which often went unanswered for over 30 minutes. Resident #4, a male with epilepsy, Todd's paralysis, hypertension, and schizoaffective disorder, reported that the response time for call lights was about an hour, with no response from the night shift. These delays in responding to call lights were corroborated by grievances filed by other residents, indicating a pattern of neglect in addressing residents' needs promptly. Interviews with staff and residents revealed ongoing issues with call light response times, with some residents waiting over an hour for assistance. The Director of Nursing acknowledged the problem and had attempted to address it by in-servicing staff and conducting unannounced visits. However, the persistent complaints and grievances suggest that the measures taken were insufficient to resolve the issue, leading to a failure in providing a safe, clean, and dignified environment for the residents.
Persistent Roach Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent infestation of roaches in various areas, including residents' rooms, nursing stations, medication carts, hallways, and the reception area. The pest control records indicate multiple treatments were conducted from February to July 2024, targeting different areas of the facility. Despite these efforts, roach activity continued to be reported in several locations, including the dining room, activities room, and reception desk. The pest control policy required monthly servicing and prompt response to pest issues, but the facility did not adhere to this policy consistently. Interviews with staff and residents revealed ongoing concerns about the roach infestation. A resident reported seeing a roach climbing the walls, and staff members, including an LVN and the DON, acknowledged the presence of roaches throughout the facility. The maintenance supervisor, responsible for coordinating pest control services, admitted to being unaware of the facility's pest control policy and confirmed the infestation had been an issue for over a year. He also noted that the pest control schedule was disrupted by a hurricane, leading to delays in treatment. The facility's pest control policy, dated April 1, 2017, required monthly servicing and a rapid response to pest issues. However, the facility's pest control efforts were inconsistent, with gaps in treatment and inadequate follow-up on reported sightings. The ongoing infestation posed a risk to the cleanliness and safety of the facility, affecting residents, staff, and visitors. Despite multiple treatments and reports of roach activity, the facility failed to effectively address the infestation, leading to continued pest presence in critical areas.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to provide immediate and appropriate respiratory care to a resident experiencing respiratory distress. The resident, who had a history of cerebral infarction, vascular dementia, and paraplegia, was observed by an LVN to be gurgling with emesis and unresponsive. Despite notifying the NP, no immediate monitoring or interventions were initiated. When the NP assessed the resident, her oxygen saturation had dropped to 60%, and she was unresponsive. Emergency services were called, but the resident was later declared brain dead and expired after artificial support was removed. The resident's care plan indicated she required extensive assistance with activities of daily living due to her cognitive and physical impairments. On the day of the incident, the resident had eaten breakfast and taken her medications as usual. However, she experienced a sudden change in condition, including vomiting and coughing, which was not promptly addressed by the facility staff. The NP attempted to provide care, including applying a non-rebreather mask and ordering oral suctioning, but the suction machine was reportedly malfunctioning, and the resident's condition continued to deteriorate. Interviews with facility staff revealed a lack of knowledge and preparedness in handling the emergency. The LVN who first responded to the resident's distress did not initiate appropriate interventions, and there was confusion about the availability and functionality of the oral suctioning equipment. The NP documented that the suction machine was malfunctioning, and there was a delay in calling emergency services. The facility's failure to provide timely and effective care placed the resident at risk of harm and ultimately contributed to her death.
Latest citations in Texas
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
