Mesa Springs Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Abilene, Texas.
- Location
- 7171 Buffalo Gap Rd, Abilene, Texas 79606
- CMS Provider Number
- 675645
- Inspections on file
- 28
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Mesa Springs Healthcare Center during CMS and state inspections, most recent first.
A resident with hemiplegia, ataxic gait, and cognitive communication deficit, who uses a wheelchair for ambulation, was transported in the facility van without being buckled in by the van driver. When the driver stopped suddenly, the resident fell from the wheelchair onto the van floor, later reporting generalized body pain and receiving pain medication after nursing assessment. Other residents reported always being buckled in during van transport. The facility’s abuse/neglect policy defines neglect and requires reporting allegations to state agencies within specified timeframes, but the Administrator did not report this incident externally, believing it was not neglect, and the transportation policy did not address securing residents in the van.
Failure to Submit PBJ Staffing Data: The facility failed to electronically submit complete and accurate PBJ staffing data to CMS for a quarter after a payroll vendor system upgrade delayed review and validation of the file. The PBJ was submitted late, an error code was not identified by the contracted service, and CMS rejected the entire file.
Improper Storage of Respiratory Equipment: Three residents receiving respiratory care had respiratory equipment left open to air or on the floor/bedside when not in use. One resident used continuous O2 via NC for hypoxic respiratory failure, another had asthma and COPD with continuous O2, and a third received nebulized Budesonide for asthma and COPD. Staff interviews confirmed NCs and nebulizer masks should be stored in plastic bags when not in use, but the facility policy did not address this storage practice.
Failure to Obtain Informed Consent for Bed Rails: The facility did not review the risks and benefits of bed rails with the resident or representative and did not obtain informed consent before bed rails were installed for three residents. One cognitively intact resident with stroke-related weakness, one resident with dementia and severe cognitive impairment, and one resident with a BKA all had bed rails or mobility bars in place, but records and staff interviews showed missing or delayed consents and no clear evidence that the required information was provided before installation.
Food was served below required temperatures when a meal cart was observed leaving the kitchen and sample trays were later tested with hot items ranging from 111 F to 130 F, below the facility’s 145 F serving standard. In a resident group meeting, 6 of 12 residents said meals were cold in their rooms and not appealing, and dietary staff confirmed they were responsible for monitoring serving temperatures while the cook was responsible for ensuring hot foods were 145 F and above.
Kitchen staff failed to date covered milk, fruit, and gelatin items in the refrigerator, left vanilla pudding cups on the pantry floor, and allowed the steam table to remain dirty with food particles and brown debris. Staff interviews confirmed that dietary aides were responsible for dating trays, all staff were responsible for keeping food off the floor, and cooks were responsible for cleaning the steam table; the facility policy required equipment to be cleaned and sanitized before use and food to be stored above floor level.
Care plans for two residents did not include bed rail use despite Bed Rail Safety Evaluations showing IDT recommendation for the rails. One resident had hemiplegia after CVA with intact cognition and used quarter rails to help with turning in bed, while the other had dementia with severe cognitive impairment and also had a quarter rail in place. Staff interviews showed they relied mainly on physician orders and acknowledged the bed rails were not added to the care plans.
A CNA had no documented dementia management training upon hire or while working at the facility, and there was also no evidence of required abuse, neglect, and exploitation education or reporting training. The ADMN and HR both acknowledged the missing training records, with HR stating the CNA’s CBT training may have been missed and the ADMN confirming she could not find proof the training had been completed.
Failure to provide QAPI training to a CNA: Record review showed CNA F had no evidence of completing required QAPI education upon hire or while employed. The ADMN said staff were expected to receive appropriate training and that she could not find documentation of CNA F’s in-service or CBT completion, while HR confirmed there was no evidence of QAPI training and said the missed training may have been overlooked when the CNA was rehired.
Missing Compliance and Ethics Training for CNA. The facility failed to include compliance and ethics training in its program and failed to ensure a CNA received required training upon hire. Record review showed the CNA had no evidence of completing the CBT or any in-service on compliance and ethics, and both the ADMN and HR confirmed there was no documentation of the training. The 2025 facility assessment listed staff training topics but did not mention compliance and ethics.
A resident with multiple medical conditions had a family member report concerns of neglect and dissatisfaction with care provided by an LVN, including allegations that wound care was not performed as ordered. Despite these concerns being communicated to facility leadership, no grievance form was completed and no investigation was initiated, contrary to facility policy requiring immediate documentation and investigation of grievances.
A facility did not follow its policy to investigate and report an allegation of neglect after a family member accused an LVN of failing to provide proper wound care to a resident with multiple medical conditions. Although the concern was communicated to facility leadership, it was not treated as a reportable allegation, and no investigation or state notification occurred as required.
The facility failed to remove expired medications and supplies from the medication room and treatment cart, including a vancomycin IV bag, lancets, IV start kits, lubricating jelly, Anasept gel, and packing iodoform strips. Staff interviews revealed a lack of awareness and responsibility for checking and removing expired items, despite existing policies. This oversight could impact the therapeutic benefits for residents.
Expired COVID and influenza testing kits were found in the medication room, posing a risk of inaccurate results. Staff interviews revealed a lack of awareness and oversight in managing expired supplies, with the DON and ADON expressing expectations for expired goods to be destroyed.
The facility failed to properly store, label, and cover food in accordance with professional standards, as observed in their kitchen operations. Unsealed and unlabeled food items were found in refrigerators and the freezer, and desserts were transported uncovered, posing a risk of cross-contamination. The Dietary Manager acknowledged these issues, and the Interim Administrator emphasized the importance of following food safety policies.
The facility failed to implement its policy on food storage for residents, leading to expired goods and inadequate temperature monitoring in personal refrigerators for three residents. A resident's refrigerator contained expired whip cream and Ranch dressing, while another's had expired cultured buttermilk without a thermometer. A third resident's refrigerator lacked a temperature log and thermometer. Staff interviews revealed confusion over monitoring responsibilities, with the Director of Maintenance unaware of the need for thermometers.
The facility failed to maintain an effective infection prevention and control program, as two staff members did not adhere to proper PPE protocols. A CMA entered a COVID-positive resident's room without a face shield and mishandled contaminated materials, while another CMA improperly cleaned a face shield. The DON acknowledged staff training on PPE but noted non-compliance with protocols.
A resident's grievance about roommate incompatibility was not properly addressed by the facility. The grievance was verbally reported to an RN, who placed it on the DON's desk, but it was never received or logged. The SW was aware of the concern but did not document it as a formal grievance. The facility's grievance policy was not followed, leading to a deficiency in addressing resident concerns.
The facility failed to conduct PASRR evaluations for two residents with serious mental disorders, including major depressive disorder and schizoaffective disorder. Despite the facility's policy requiring PASRR evaluations upon admission, these residents were not referred for necessary evaluations, potentially affecting their access to specialized services. Staff interviews revealed issues with adherence to policy and staff turnover as contributing factors.
A resident with severe cognitive impairment and a history of falls had a care plan requiring his wheelchair to be placed at his bedside to prevent falls. However, the wheelchair was found in the bathroom, contrary to the care plan, due to staff misunderstanding. The resident's family raised concerns, and the DON acknowledged the error, attributing it to miscommunication.
A facility failed to change a resident's oxygen tubing weekly as per physician's orders, risking respiratory complications. The resident, with severe cognitive impairment and multiple health issues, was found with tubing unchanged since 01/06. The DON confirmed the oversight, attributing it to a lapse in protocol adherence, despite random checks by nursing leadership.
A treatment cart containing medications and medical supplies was left unlocked and unattended at a nurses' station, with residents present in the area. RN G admitted to forgetting to lock the cart due to being in a hurry, and the DON confirmed that the expectation was for all carts to be locked when not in use.
The facility failed to ensure privacy for two residents, leading to deficiencies in maintaining dignity. One resident was left uncovered during care without a privacy curtain, while another lacked a privacy curtain in her room. Staff interviews confirmed these oversights, which violated the facility's policy on resident rights.
A resident reported being verbally abused by her roommate, but the facility failed to conduct a thorough investigation. Despite staff witnessing the abuse and reporting it, the administrator did not fully investigate, mistaking the issue for a family dispute. The facility's policy requires immediate protection and thorough investigation of abuse allegations, which was not followed in this case.
A resident with Alzheimer's and dementia experienced a fall resulting in a forehead laceration requiring emergency treatment. The facility failed to update the resident's care plan to address the fall, despite having a policy for comprehensive person-centered care planning. Interviews revealed that the incident was not flagged for care planning during morning meetings, leading to a lapse in updating the care plan.
Failure to Report Van Transport Incident as Potential Neglect
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse and neglect policies by not reporting an incident of potential neglect to the state agency within the required timeframe. A female resident with hemiplegia affecting the right dominant side, ataxic gait, and a cognitive communication deficit, who required a wheelchair for ambulation and had a BIMS score of 99 (unable to assess cognitive impairment), was being transported back from a dental appointment in the facility van. During this transport, the van driver failed to buckle the resident into her wheelchair. When the van stopped suddenly, the resident fell out of her wheelchair and onto the floor near the driver’s seat. Nursing documentation showed that on the date of the incident, the van driver reported that the resident had fallen from her wheelchair and rolled over near the driver’s seat and that she did not have a seat belt on at the time the van stopped. A nurse assessed the resident upon return to the facility; the resident complained of generalized body pain but had no documented injuries and received pain medication, which was recorded on the Medication Administration Record. In an interview, the resident confirmed she had not been buckled in, that the driver had to stop suddenly, and that she fell onto the floor of the van. She stated that the driver assessed her, helped her back into the wheelchair, and then secured her with a strap, and she reported that she had always been buckled in on prior trips. Interviews with other sampled residents who used the van indicated they reported always being buckled in during van rides. The facility’s abuse prevention policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and stated that allegations of abuse or neglect would be reported outside the facility to appropriate state or federal agencies within applicable timeframes. The Administrator acknowledged that an internal investigation determined the van driver had failed to buckle the resident in but stated she did not report the event to the state because she did not consider it neglect. The facility’s transportation policy for diagnostic appointments did not address the requirement to buckle or secure residents while using the van.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for FY Quarter 4 2025, based on payroll and other verifiable and auditable data in the required uniform format. Review of the Staffing Data Report showed the facility triggered for Failed to Submit Data for the quarter, and the PBJ nurse staffing levels for October 1 through December 31, 2025 reflected reported hours for total nurse, RN, LVN, nurse aide, and PT staffing, but the submission was not accepted by CMS. During interview, the ADMN stated the facility had upgraded its payroll vendor system in January and February 2026, which caused an unanticipated delay in reviewing and validating the information for submission. She stated the PBJ was submitted after 5:00 p.m. on February 13, 2026, but an error code was not identified by the contracted service, and the issue was not discovered until after the submission error occurred. Record review of the facility's Process Improvement Plan for F851 stated the PBJ file failed to submit successfully before the deadline due to an inadvertent coding error following a system upgrade, causing CMS to reject the entire file.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment was properly stored when not in use for three residents receiving respiratory care. Resident #19 had a history of hypoxic respiratory failure and was ordered oxygen at 2-4 liters per minute via nasal cannula to keep oxygen above 90 percent. Resident #24 had diagnoses of asthma and COPD and was ordered continuous oxygen at 2 liters per minute via nasal cannula. Resident #31 had asthma and COPD and was ordered Budesonide inhalation suspension twice daily for asthma and COPD. On observation, Resident #24's nasal cannula was found left open to air and on the floor in an empty room. Resident #31's nebulizer mask was observed on the nightstand, open to air and uncovered; the resident stated the staff had administered her medication that morning and that the mask was usually stored in a plastic bag. Resident #19's nasal cannula was observed left on the bed in an empty room. During interviews, CNA H stated nasal cannulas and nebulizer masks should be stored in plastic bags when not in use to prevent contamination and that all staff were responsible for proper storage. RN I stated the items needed to be stored in a bag when not in use and should be discarded if not stored properly. The DON also stated oxygen tubing and masks were to be stored in a bag when not in use and that not storing them in bags was an infection control issue. Review of the facility's undated Oxygen Administration policy did not address storage of oxygen tubing or nebulizer masks when not in use.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to review the risks and benefits of bed rails with residents or their representatives and failed to obtain informed consent before bed rails were installed for 3 of 5 residents reviewed. The deficiency involved Resident #2, Resident #3, and Resident #6, all of whom had bed rails or mobility bars on their beds and were identified in the record review as having bed rail safety evaluations completed by the interdisciplinary team. Resident #2 was a cognitively intact female with hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and dependence for much of bed mobility and transfers. Her record reflected a bed rail safety evaluation stating that bed rails were recommended and that resident education and informed consent should be confirmed before installation. During observation, she had quarter rails on both sides of the bed and stated she used them to help with turning, but she could not state the risks of having the rails. The record did not show a physician order for the bed rail, and staff interviews reflected uncertainty about when the rails were placed and who obtained the consent. Resident #3 was a female with dementia, severe cognitive impairment, muscle weakness, need for assistance with personal care, and unsteadiness on feet. Her record also reflected a bed rail safety evaluation recommending bed rails and stating that resident education and informed consent should be obtained before installation. During observation, she had a quarter rail on the right side of the bed. Her representative stated he had no concerns about her care, did not know when the bed rails were placed, and could not remember whether he had signed a consent for the rail. Resident #6 was a cognitively intact male with a right below-knee amputation and neuropathy who required assistance with bed mobility and transfers. His physician order allowed mobility bars to aid turning and repositioning in bed, and his bed rail safety evaluation recommended bed rails and stated that informed consent should be confirmed before installation. The record showed that the bed side rail consent was signed 17 days after the safety evaluation and 23 days after the physician order. During observation, he had a side rail on the right side of the bed and stated he used it to help get out of bed and move while in bed. Interviews with nursing staff and the DON showed that the facility did not have the consent in the chart for Resident #2 or Resident #3 prior to 03/18/2026 and that the consent for Resident #6 should have been obtained sooner.
Food Served Below Required Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures. During an observation on 03/17/26 at 12:10 PM, the meal cart for the 100-hall left the kitchen and the last tray was delivered to a resident room at 12:23 PM. When sample trays were tested at 12:25 PM, all meal entrees were below the facility’s serving temperature standard, including the mechanical, regular, and puree diets. The tested items included Steak Fritters, [NAME] Beans, Red Potatoes, and Mashed Potatoes, with temperatures ranging from 111 F to 130 F. During a confidential resident group meeting on 03/18/26 at 9:30 AM, 6 of 12 residents reported dissatisfaction with the meals and stated the food was cold when received in their rooms and the appearance was not appealing. They also stated these concerns had been reported to staff before. In interviews on 03/19/26, Dietary staff and the Dietary Manager stated meal serving temperatures were to be at least 145 F, that they monitored temperatures before serving, and that the cook was responsible for ensuring food temperatures were 145 F and above. Record review of the facility’s Infection Control Policy/Procedure stated that hot foods must be kept at 140 F or above.
Kitchen Food Storage, Dating, and Sanitation Lapses
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During the initial kitchen observation on 03/17/26, surveyors found a serving tray with multiple cups of milk covered with plastic wrapping, three small bowls of served fruit covered with plastic wrapping, and a cup of gelatin in the walk-in refrigerator that were not dated. The same observation also identified two boxes of vanilla pudding cups on the floor in the walk-in pantry. Later that morning, the steam table was observed with food particles and brown debris in the metal compartments in the water of the steam table. In interview, Dietary Aide G stated the dietary staff were responsible for dating trays with food and drinks, that all staff were responsible for keeping food items off the floor, and that the steam table was to be cleaned and maintained by the cook. She also stated the dishwasher and the [NAME] were responsible for monitoring sanitation levels before washing dishes, and that improper sanitation could result in dishes and utensils not being cleaned or sanitized correctly. The Assistant Dietary Manager stated the dietary aides who prepped trays with drinks and food were responsible for dating them and that the trays should have a 3-day date. She stated the vanilla pudding cups were not to be on the floor and that all staff were responsible for removing food items from the floor. She also stated the steam table was to be clean before and after meals and that dirty water or food particles in it should be cleaned and changed. The Dietary Manager stated dietary aides were responsible for dating trays, all kitchen staff were responsible for storing food off the floor, cooks were responsible for cleaning the steam table, and all staff were responsible for monitoring dishwasher chemical levels. The facility policy stated all equipment must be cleaned and sanitized before use, food must be stored above floor level and away from the wall, and work areas, floors, and dietary equipment must be kept as clean as possible throughout the work day.
Care Plans Missing Bed Rail Interventions for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for 2 of 16 residents reviewed for care plans. Resident #2 was an [AGE]-year-old female with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and muscle weakness. Her quarterly MDS dated 03/04/2026 showed a BIMS score of 14, indicating intact cognition, and she required a helper to do more than half of the effort for bed mobility and transferring from bed to chair. Her comprehensive care plan reviewed on 03/17/2026 did not include evidence that she utilized a bed rail, and her physician orders also did not reflect a bed rail order. Resident #2’s medical record included a Bed Rail Safety Evaluation dated 03/11/2026 that stated the IDT recommended a bed rail and directed staff to proceed with resident education regarding risks and benefits and to confirm informed consent before installation. During observation and interview on 03/17/2026, Resident #2 was lying in bed with quarter rails on both sides and stated she used the rails to help with turning in bed and wanted to continue having them on her bed. Despite this, the care plan did not reflect the bed rail use. Resident #3 was an [AGE]-year-old female admitted with diagnoses including dementia, muscle weakness, need for assistance with personal care, and unsteadiness on feet. Her quarterly MDS dated 01/26/2026 showed a BIMS score of 0, indicating severe cognitive impairment, and she required assistance for bed mobility and was dependent on a helper for transferring from bed to chair. Her comprehensive care plan reviewed on 03/17/2026 did not include evidence that she utilized a bed rail, and her physician orders also did not reflect a bed rail order. Her record contained a Bed Rail Safety Evaluation dated 03/12/2026 stating the IDT recommended a bed rail and that resident education and informed consent should be obtained before installation. During observation on 03/17/2026, Resident #3 was lying in bed with a quarter rail on the right side.
Missing Required Dementia and Abuse Training for CNA
Penalty
Summary
The facility failed to provide dementia management training for CNA F, a staff member reviewed for required education. Record review showed CNA F had a hire date of 12/30/2025, and HR records contained no evidence that she completed dementia management training upon hire or while working at the facility. The facility’s records also showed that CNA F had no documented training on abuse, neglect, and exploitation reporting, despite the facility assessment identifying these topics as required training for direct care staff and nurse aides. During interviews, the ADMN stated she expected staff to have appropriate training per regulations and acknowledged the facility did not have a training policy, relying instead on regulations for orientation and annual training. She stated she believed an in-service had been done but could not find CNA F’s signature, and the CBT program also showed no evidence of dementia management training for CNA F. HR stated she was responsible for ensuring staff completed CBT training, but she was new to the position and may have missed that CNA F had not completed the dementia care training. HR also stated there was no evidence CNA F had completed the training before her hire date because CNA F had quit and been rehired, and she confirmed there was no evidence CNA F had training on dementia care.
Failure to Provide QAPI Training to CNA
Penalty
Summary
Mandatory training on the facility’s QAPI program was not provided to all staff, as the facility failed to ensure CNA F completed QAPI education upon hire. Record review showed CNA F had a hire date of 12/30/2025, and the HR record contained no evidence that CNA F completed QAPI training either at hire or while working at the facility. The facility’s Facility Assessment identified QAPI as one of the training topics available for direct care staff, and the CBT program was listed as a resource for training and competency validation. During interview, the ADMN stated she expected staff to receive appropriate training per regulations and said the facility did not have a training policy, instead following regulations for orientation and annual training. She stated she believed an in-service had been done but could not find CNA F’s signature, and the CBT program also showed no evidence of QAPI training completion. The HR stated she was responsible for ensuring staff completed CBT training, acknowledged she had no evidence CNA F completed QAPI training, and said CNA F had previously quit and been rehired, which she believed may have contributed to the missed training.
Missing Compliance and Ethics Training for CNA
Penalty
Summary
The facility failed to include compliance and ethics training as part of its compliance and ethics program, including an effective way to communicate the program's standards, policies, and procedures through training or another practical method. The report states that the facility also failed to provide annual training for all new and existing staff for an organization operating 5 or more facilities, and this was identified for 1 of 18 staff reviewed, CNA F. Record review showed CNA F was hired on 12/30/2025 and had no evidence of completing compliance and ethics training upon hire or while working at the facility. During interviews, the ADMN stated she expected staff to receive appropriate training per regulations, said the facility did not have a training policy and relied on regulations for orientation and annual training, and confirmed she could not find CNA F's signature on any in-service record or evidence in the CBT program. The HR stated she was responsible for ensuring staff completed CBT training, was new to the position, and had no evidence that CNA F completed compliance and ethics training. The facility assessment for 2025 listed training topics for staff, including direct care staff, but did not mention compliance and ethics training.
Failure to Address Resident Grievance Regarding Nursing Care
Penalty
Summary
The facility failed to ensure that a resident's grievance regarding the care provided by an LVN was properly addressed according to its grievance policy. A resident with multiple complex medical conditions, including dementia, chronic kidney disease, pressure ulcer, and other comorbidities, had a family member who verbally reported concerns about neglect and dissatisfaction with the care provided by an LVN. The family member specifically requested that the LVN not provide care to her family member and expressed concerns that the LVN was responsible for the resident's wound and decline, alleging that dressing changes were not performed as ordered. Despite these concerns being reported to both the Marketer and the Administrator, no grievance form was completed, and no investigation was initiated by the facility. The Administrator stated she was unsure of the grievance policy and did not act because the family member mentioned contacting the State. The DON did not recall being informed of the concerns and did not believe the comments warranted an investigation. The facility's policy required that grievances be documented and investigated immediately, with written decisions provided if requested, but this process was not followed in this instance. Interviews with staff confirmed that the family member's concerns were communicated to facility leadership, but there was a lack of follow-through in initiating the grievance process. The facility's failure to document and investigate the grievance as required by policy resulted in the resident's complaint not being formally addressed, potentially leaving the concern unresolved.
Failure to Investigate and Report Alleged Neglect
Penalty
Summary
The facility failed to implement and follow its written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for one resident. Specifically, the facility did not investigate or report an allegation of neglect to the Texas Health and Human Services Commission (HHSC) as required by its own policy. The incident involved a family member alleging that an LVN neglected a resident, but the facility did not initiate the mandated investigation or reporting process. The resident involved was an elderly female with multiple complex medical diagnoses, including dementia, chronic kidney disease, pressure ulcer, diabetes, Parkinson's disease, and heart failure. Her care plan and physician's orders required specific wound care interventions, which were documented as being performed as ordered. Despite this, the family member expressed concerns that the LVN did not perform dressing changes as required, leading to the resident's wound worsening and subsequent hospitalization. The family member communicated these concerns to the facility's Marketer, who then reported them to the Administrator. Interviews with facility staff revealed that the Administrator and DON were aware of the family member's dissatisfaction and anger, particularly toward the LVN, but did not interpret the complaint as an allegation of neglect or abuse. As a result, the required investigation and reporting to the State were not initiated. The facility's policy clearly defined neglect and outlined procedures for immediate reporting and investigation, but these procedures were not followed in this instance.
Expired Medications and Supplies Not Removed
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not removing expired medications and supplies from the medication room and treatment cart. During an observation, it was found that a vancomycin IV bag, lancets, IV start kits, lubricating jelly, Anasept gel, and packing iodoform strips were expired and had not been removed. These items were found in one medication room and one treatment cart, indicating a lapse in the facility's procedures for managing pharmaceutical supplies. Interviews with staff revealed a lack of awareness and responsibility regarding the removal of expired items. LVN H admitted to not being aware of the expired items on the treatment cart, as they were not used in recent treatments. LVN F acknowledged the presence of expired items in the medication room and expressed uncertainty about the potential risks of using such items. MA E, responsible for the medication room, was unaware of the need to check for expired supplies, despite being in charge for five months. The facility's policies on the disposal and storage of medications were not adhered to, as evidenced by the presence of expired items. The ADON and DON both stated that expired goods should be destroyed and not stored, and they acknowledged the oversight in the facility's procedures. The failure to remove expired medications and supplies could potentially impact the therapeutic benefits for residents, as noted by the DON.
Expired Testing Kits Found in Medication Room
Penalty
Summary
The facility failed to ensure the quality of laboratory services by not removing expired COVID and influenza testing kits from the medication room. During an observation, it was found that two boxes of COVID testing kits had expired on December 15, 2023, and one box along with four packages of influenza A & B tests had expired on November 30, 2024. These expired kits were still present in the medication room, which could lead to inaccurate testing results for residents. Interviews with staff revealed a lack of awareness and oversight regarding the management of expired supplies. LVN F acknowledged that expired tests should be disposed of and recognized the risk of inaccurate results from using expired kits. MA E, who was responsible for the medication room, admitted to not knowing she should check for expired supplies. The ADON and DON both expressed that their expectation was for expired goods to be destroyed and not stored in the medication room. The DON noted that the lead MA was responsible for weekly checks, and the failure to remove expired supplies was due to oversight.
Food Storage and Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During inspections, it was noted that food items in Refrigerator #1, Refrigerator #2, and the freezer were not properly sealed or labeled. Specifically, a bin of celery and a box of muffins in Refrigerator #1, a box of sausage in Refrigerator #2, and a box of cannoli in the freezer were all found unsealed and exposed to air. The Dietary Manager (DM) acknowledged these issues, stating that such products should be stored in sealed containers to prevent cross-contamination, which could lead to residents becoming ill. The DM also mentioned that continuous training is provided to staff on proper food storage practices. Additionally, during the transportation of food from the kitchen to resident areas, it was observed that cakes on hall carts were uncovered, which the DM admitted could lead to cross-contamination. The DM explained that the failure to cover the desserts was due to staff being in a hurry and mistakenly believing that covering the entire cart was sufficient. The Interim Administrator (ADMN) confirmed that staff should follow policies for dating and labeling food to prevent the risk of residents consuming expired or contaminated food. The Social Worker (SW) noted that all but one resident consumed food from the kitchen, highlighting the potential widespread impact of these deficiencies.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors, leading to unsafe and unsanitary conditions for three residents. Resident #36's personal refrigerator contained expired goods, such as whip cream and Ranch dressing, and lacked a consistent temperature log for the month. Resident #36 was unaware of the expired items due to difficulty reading small labels and requested assistance in disposing of them. Resident #65's personal refrigerator also contained expired goods, specifically cultured buttermilk, and lacked a thermometer to monitor the temperature. The temperature log on the refrigerator was incomplete, with no date or year, and Resident #65 was unaware of the expired items and relied on staff or visitors for assistance. A visitor removed the expired buttermilk to prevent accidental consumption. Resident #23's personal refrigerator did not have a thermometer and lacked a temperature log for the month. The refrigerator contained drinks and food items, including cake in a Styrofoam container. Interviews with facility staff revealed confusion about responsibility for monitoring personal refrigerators, with housekeeping and nursing staff providing conflicting information. The Director of Maintenance, who recently assumed the housekeeping supervisor role, was unaware of the need for thermometers in personal refrigerators.
Inadequate Infection Control Practices by Staff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two staff members, CMA J and CMA K, who did not adhere to proper PPE protocols. CMA J entered a COVID-positive resident's room without wearing a face shield, despite being aware of the requirement to do so. Additionally, CMA J dropped a glove on the floor and continued to assist the resident without replacing it, further compromising infection control measures. CMA J also failed to properly dispose of contaminated materials, placing a tray wrapped in a contaminated bag on the medication cart in the hallway. CMA K was observed carrying a face shield down the hallway to clean it with bleach wipes, instead of cleaning it immediately after exiting a resident's room. This action was contrary to infection control protocols, which require PPE to be cleaned or disposed of before leaving the room. The Director of Nursing acknowledged that staff had been trained on PPE usage but did not follow their training or the facility's policies, which contributed to the potential exposure of residents to COVID-19.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to ensure that residents had the right to voice grievances regarding their care and treatment, as well as other concerns related to their stay. This deficiency was identified for one resident, who was admitted with diagnoses including unspecified dementia, muscle weakness, anxiety disorder, and major depressive disorder. The resident's representative made a verbal grievance to an RN about the resident's incompatibility with her roommate, but the grievance was not properly investigated or resolved by the facility. The RN who received the grievance placed it on the DON's desk, but the DON stated she never received it. The grievance coordinator, who was a different administrator at the time, was not aware of the grievance, and the grievance was not logged in the facility's grievance log. The SW was aware of the concern about the roommate but did not document it as a formal grievance, as she did not receive a formal grievance form. The facility's grievance policy requires that grievances be logged and investigated, but this process was not followed in this case. The facility's grievance log for December did not contain any record of the grievance, and the last grievance listed was dated several days before the incident. The facility's policy outlines that the grievance official is responsible for overseeing the grievance process, but there was a lack of clarity and communication among staff regarding the handling of grievances. This failure to properly address and document the grievance could place residents at risk of not having their concerns heard and resolved.
Failure to Conduct PASRR Evaluations for Residents with Mental Illness
Penalty
Summary
The facility failed to refer two residents for a Pre-Admission Screening and Resident Review (PASRR) evaluation despite their diagnoses of serious mental disorders. Resident #27, a female with major depressive disorder and post-traumatic stress disorder, and Resident #29, a female with schizoaffective disorder, bipolar disorder, and major depressive disorder, were not referred for PASRR evaluations. This oversight was identified through interviews and record reviews, which revealed that neither resident had undergone the necessary PASRR evaluation, potentially impacting their access to specialized therapy and services. Interviews with facility staff, including the social worker and MDS coordinator, highlighted a lack of adherence to the facility's PASRR policy. The MDS coordinator acknowledged the absence of a PASRR evaluation for the residents and attributed it to staff turnover and the absence of a dedicated MDS coordinator at the facility. The facility's policy mandates PASRR evaluations upon admission and appropriate referrals for specialized services, but there was no evidence of such evaluations being conducted for the residents in question. The MDS coordinator also noted that the facility lacked policies for addressing suspected mental illness after admission.
Failure to Follow Care Plan for Wheelchair Placement
Penalty
Summary
The facility failed to adhere to the care plan for a resident with a history of falls and severe cognitive impairment. The resident, who was diagnosed with Alzheimer's disease, chronic kidney disease, and lack of coordination, had a care plan intervention that required his wheelchair to be placed at his bedside to reduce the risk of falls. However, during an observation, it was noted that the wheelchair was placed in the bathroom instead of at the bedside, contrary to the care plan. This misplacement was discovered by the resident's family, who expressed concern due to the resident's recent history of falls. Interviews with facility staff revealed a misunderstanding regarding the placement of the wheelchair. A CNA admitted to moving the wheelchair to the bathroom, believing it was necessary because the resident was COVID positive and weak, and she was unaware of the care plan requirement. The Director of Nursing acknowledged that the wheelchair should have been at the bedside as per the care plan and attributed the failure to miscommunication among staff. The facility's policy on fall prevention emphasizes the need to follow care plans to prevent falls, but this was not adhered to in this instance.
Failure to Change Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not changing the oxygen tubing weekly as per the physician's order. Resident #12, a male with severe cognitive impairment and multiple health conditions including Alzheimer's disease, chronic kidney disease, heart disease, and a history of COVID-19, was observed with oxygen tubing that had not been changed since 01/06, despite the requirement for weekly changes. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the tubing should have been changed every Sunday night shift. The DON stated that the responsibility for changing the oxygen tubing lay with the Sunday night shift nurse, and that random checks were conducted by the DON and the Assistant Director of Nursing (ADON) to ensure compliance. However, the failure to change the tubing was attributed to oversight, which could potentially lead to respiratory complications or infections for residents using oxygen. The facility's policy, dated 05/2007, also stipulated that oxygen tubing should be replaced weekly, underscoring the lapse in adherence to established protocols.
Failure to Secure Treatment Cart with Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with a treatment cart left unlocked and unattended at the nurses' station. This cart contained various medications and medical supplies, including insulin pens, needles, lancets, inhalers, and other prescription medications. During an observation, it was noted that the treatment cart was left unsecured with residents present in the area, posing a risk of unauthorized access to the medications. RN G, who was responsible for the treatment cart, admitted to leaving it unlocked due to being in a hurry to get to the dining room. The Director of Nursing (DON) confirmed that the expectation was for all medication and treatment carts to be locked when not in use, and acknowledged that carelessness led to the failure of securing the cart. The facility's policy mandates that only authorized personnel have access to medications, and that medication carts should be locked or attended by authorized individuals.
Privacy Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure personal privacy for two residents, leading to deficiencies in maintaining dignity and respect. For one resident, CNAs A and B did not provide full privacy during incontinent care, as observed on video. The resident was left uncovered and undressed while waiting for RN C, and the privacy curtain was not pulled, even though the door was shut. This oversight allowed the resident to be visible from the hallway when the door was opened. Interviews with the CNAs and RN C confirmed that the privacy curtain was not used, despite the resident being unclothed. Another resident did not have a privacy curtain installed in her room, as observed during a facility visit. The resident confirmed the absence of a privacy curtain, although her roommate had one. RN C acknowledged that all rooms should have privacy curtains and was unsure why this particular room lacked one. The facility's policy on resident rights emphasizes the importance of privacy and dignity, which was not upheld in these instances.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident. The incident involved a resident who reported being verbally abused by her roommate, which was not properly investigated by the facility. The resident, who was mildly cognitively impaired, expressed that her roommate was verbally abusive daily, calling her names and making fun of her. Despite the resident's distress, the facility did not have evidence of a thorough investigation into the allegations. Interviews with staff revealed that a CNA overheard the verbal abuse and reported it to the charge nurse, who then contacted the administrator. However, the administrator did not conduct a full investigation, mistakenly believing the issue was between the resident and a family member rather than between the two residents. The administrator acknowledged that a more thorough investigation should have been conducted, which would have led to better room placement for the residents involved. The facility's policy on abuse prevention requires immediate steps to protect residents and a prompt, thorough investigation of any allegations. However, in this case, the facility did not comply with its policy, as the investigation was not completed, and the resident continued to experience verbal abuse. This failure to investigate thoroughly could place residents at risk of further abuse.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident following a fall incident, which was identified during a comprehensive assessment. The resident, a female with Alzheimer's Disease, muscle weakness, unspecified lack of coordination, and dementia, experienced a fall on April 29, 2024, resulting in a forehead laceration that required emergency treatment. Despite the incident, the resident's care plan, dated June 25, 2024, did not address the fall, indicating a lapse in updating the care plan to reflect the resident's current needs. Interviews with facility staff revealed that the normal process involves updating care plans during morning meetings when changes in a resident's condition occur. However, the fall incident involving the resident was not flagged for care planning, leading to a failure in updating the care plan. The facility's policy requires the interdisciplinary team to develop comprehensive person-centered care plans that include measurable objectives and timeframes, but this was not adhered to in this case, as the resident's fall was not incorporated into her care plan.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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