Methodist Transitional Care Center-desoto Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Desoto, Texas.
- Location
- 109 Methodist Way, Desoto, Texas 75115
- CMS Provider Number
- 676492
- Inspections on file
- 47
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Methodist Transitional Care Center-desoto Llc during CMS and state inspections, most recent first.
The facility did not ensure that G-tube dressings were changed and dated as ordered for multiple residents, and failed to keep formula tubing capped during downtime, leaving tube ends exposed and uncapped. These lapses were observed through direct inspection, family reports, and staff interviews, with documentation inconsistencies and lack of staff awareness contributing to the deficiencies.
A resident with multiple medical conditions alleged that a medication aide attempted to force medication after she refused it. The DON filed a grievance and suspended the aide, but after an internal investigation and consultation with corporate, the incident was not reported to the State Agency within the required two-hour timeframe, as staff believed it was not reportable. This failure to report the allegation as required resulted in a deficiency.
A resident with a PICC line for IV antibiotics did not have her dressing changed as ordered, with the dressing remaining in place beyond the required interval. Nursing staff cited workload and communication lapses as reasons for missing the scheduled dressing change, and the infection control preventionist and DON were unaware of the overdue dressing until it was identified during the survey.
A resident was denied access to a private telephone after a family member requested the removal of all communication devices, despite the resident being able to make decisions and having no diagnosis of dementia. Facility staff, including the DON and Administrator, complied with the family member's request and instructed staff not to provide a phone, even though facility policy and the resident's records supported the resident's right to communication.
Medication Cart #1 was found unlocked and unattended in a hallway, with no staff present nearby. A medication tech, responsible for two carts, admitted to forgetting to lock the cart when switching between them. Both the DON and Administrator confirmed the incident, and the facility's policy on locked medication carts was not provided when requested.
The facility did not ensure that calls to centralized staff areas were consistently answered and failed to maintain functioning portable phones at nurses' stations, resulting in missed communications for 17 residents. Staff interviews and surveyor observations confirmed that after-hours calls often went unanswered, and portable phones were either missing or not properly charged, impeding residents' and representatives' ability to reach staff regarding care concerns.
The facility did not ensure privacy for resident council meetings, holding them in an open activities room where staff and providers repeatedly entered and interrupted the sessions. Leadership confirmed that private meeting spaces were unavailable due to other uses, and residents reported frequent disruptions during their meetings.
A resident with stage IV pressure ulcers had a negative pressure wound device set above the physician-ordered setting on two consecutive days. Nursing staff were unclear about the correct settings, and the device was only adjusted after the discrepancy was identified. Facility policy required verification of orders and correct device settings, which was not followed.
Surveyors found that kitchen staff failed to properly label, date, and seal food and drinks in the refrigerator and dry storage, and did not separate dented cans from other food items. Staff interviews confirmed these responsibilities were not met, potentially exposing residents to expired or contaminated food.
A resident with significant medical needs did not receive timely assistance with grooming and incontinence care due to staff failing to respond promptly to call lights. Interviews and records indicated that staff sometimes turned off call lights without providing care, leading to delays in meeting the resident's needs and causing dissatisfaction.
A medication aide failed to sanitize a blood pressure cuff and perform hand hygiene before contact with two residents, both with significant medical histories, while administering medications and checking vital signs. This occurred despite facility policies and in-service training requiring hand hygiene and disinfection of shared equipment between resident contacts. The DON and Administrator confirmed these expectations during interviews.
A resident with dementia and impaired cognition was discharged home alone without appropriate supervision, care arrangements, or necessary services in place. The discharge was carried out despite documented concerns about the resident's ability to care for herself, an unsafe home environment, and lack of involvement from responsible parties or medical providers. The facility did not complete required assessments or ensure post-discharge support, resulting in the resident being left in an unsafe situation.
Four residents with complex medical needs did not have person-centered care plans that included measurable objectives or discharge planning, despite their varied conditions and imminent plans to return home. Staff interviews confirmed that care plans were not updated to address discharge goals, and the facility could not provide a care plan policy when requested.
A resident with dementia and cognitive deficits experienced a significant decline in mental status, including increased confusion and need for assistance with ADLs. Despite these changes, staff did not complete a Significant Change in Status Assessment as required, and the resident's care plan was not updated to reflect her altered condition. Staff interviews confirmed the assessment should have been completed when the resident's cognitive status declined.
A resident with a history of multiple health issues experienced severe pain after an unwitnessed fall in a LTC facility. Despite orders for pain medication, there was a delay in administration, and the resident's pain was not adequately assessed or managed. The resident was later diagnosed with a hip fracture requiring surgery. Communication lapses and a lack of timely intervention by staff contributed to the deficiency.
A resident with a history of falls experienced a deficiency in care after a fall, as the facility failed to conduct routine neuro checks and adequately manage pain. Despite physician orders for pain medication and monitoring, the resident's pain assessments were not documented, and medication administration was delayed. The resident's condition worsened, leading to a hospital diagnosis of a hip fracture requiring surgery. Interviews revealed lapses in communication and documentation among staff.
A resident with a history of falls did not have the administration of Tylenol documented on the Medication Administration Record after a fall. LVN A failed to conduct and document pain assessments and neuro checks, despite the resident expressing pain. The incident report was delayed, and the facility's documentation policies were not followed, leading to a deficiency.
A resident with a history of falls experienced an unwitnessed fall and subsequent pain, but the family was not notified immediately. The resident was later diagnosed with a hip fracture requiring surgery. The facility's staff, including the LVN responsible, failed to inform the family, contrary to the facility's policy.
A resident with a history of falls and cognitive impairment was repeatedly found without access to their call light, despite facility policy and staff acknowledgment of its importance in preventing falls. Observations showed the call light was often placed out of reach, and staff interviews confirmed the expectation for it to be accessible at all times.
The facility failed to properly store, date, and label food items in the kitchen's walk-in freezer, exposing them to potential contaminants. Open cases of frozen cookies and hamburger patties, along with an uncovered coil of sausage, were found without proper labeling or packaging. The Dietary Manager confirmed these actions were against the facility's policy, which requires all food to be sealed, labeled, and dated.
A CNA failed to perform hand hygiene while serving meals to four residents, despite being trained on infection control procedures. The residents had various medical conditions, including atrial fibrillation, dementia, and diabetes, and required assistance with daily activities. The DON confirmed the importance of hand hygiene to prevent infection spread.
Failure to Provide Proper G-Tube Care and Maintain Closed Feeding Systems
Penalty
Summary
The facility failed to provide appropriate care and services to prevent complications related to enteral feeding for four residents with gastrostomy tubes. Specifically, the facility did not ensure that gastrostomy tube (G-tube) dressings were changed and dated as ordered for three residents. In one case, a resident's family reported finding the G-tube dressing soiled with a foul odor and the feeding tube end uncapped and dirty over multiple days. Documentation in the Medication Administration Record (MAR) indicated that dressing changes were marked as completed, but observations and family-provided photos contradicted this, showing undated and soiled dressings. Interviews with nursing staff revealed uncertainty about when dressings were last changed and acknowledged that not dating dressings could lead to confusion about care provided. Additionally, the facility failed to ensure that formula tubing was sealed with a cap during downtime for two residents. Observations showed that the feeding tube ends were left uncapped and hanging from IV poles when not in use, creating an open system. Staff interviews confirmed that the expectation was to use the clear plastic cap provided with the formula bags to close the line when not connected to the resident, but this was not consistently done. Some staff were unaware of the importance of capping the tubing or did not consider it within their responsibilities. The facility's policies required daily dressing changes, proper documentation, and infection control practices to prevent contamination and infection. However, interviews with the infection control preventionist, DON, and administrator revealed a lack of awareness and oversight regarding missed dressing changes and undated dressings. The failure to follow established protocols for G-tube care and formula tubing management was observed and confirmed through interviews, record reviews, and photographic evidence.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury. Specifically, an allegation of abuse made by a resident was not reported to the State Agency within the required timeframe. The resident, a female with diagnoses including gastrostomy malfunction, COPD, type 2 diabetes, unspecified dementia, and cellulitis of the abdominal wall, reported to the DON that a medication aide had pinched her mouth and attempted to force medication after she refused it due to its taste. The resident's family was present at the time of the allegation. Upon receiving the allegation, the DON filed a grievance, suspended the medication aide pending investigation, and completed life satisfaction surveys for abuse and neglect. The DON reported the incident to the facility's abuse coordinator (the Administrator) and the corporate office. However, after an internal investigation and consultation with the corporate office, it was determined that the incident was not reportable to the State Agency, as there was a witness present and the family later suggested the resident may have been confused due to dementia. As a result, the incident was not reported to the State Agency as required by regulation. Interviews with facility staff confirmed awareness of the two-hour reporting requirement for abuse allegations. The Administrator acknowledged that the incident was not reported to the State Agency based on corporate guidance and the internal investigation's findings. Facility records showed that in-service training on abuse and neglect was conducted after the incident, but the initial failure to report the allegation within the mandated timeframe constituted a deficiency.
Failure to Timely Change PICC Line Dressing per Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that parenteral fluids were administered in accordance with professional standards of practice and physician orders for a resident with a PICC line. The resident, a female admitted with an active infection related to hardware in her right lower leg, was receiving IV antibiotics through a PICC line. Physician orders specified that the PICC line dressing should be changed every seven days and as needed, and the facility's policy also required weekly dressing changes or sooner if the dressing was not intact. During observation, it was noted that the resident's PICC line dressing was dated 14 days prior and was coming off on one side, although the immediate area around the insertion site was clean and intact. Interviews with nursing staff revealed that the dressing change had been missed; one LVN admitted she noticed the overdue dressing but delayed changing it until after administering antibiotics, while another LVN responsible for the dressing change stated she forgot due to being busy with admissions and discharges and failed to communicate this to the oncoming nurse. The infection control preventionist and DON both confirmed that the dressing change had not been completed as ordered and were unaware of the overdue status until the survey. Record review and staff interviews confirmed that the facility's policy and physician orders were not followed, resulting in the PICC line dressing remaining unchanged for longer than the prescribed interval. The staff acknowledged that the failure to change the dressing as ordered could increase the risk of infection, and the breakdown in communication and time management contributed to the deficiency.
Failure to Provide Resident Access to Private Communication
Penalty
Summary
The facility failed to ensure a resident had access to a private form of communication, specifically by removing the landline telephone from the resident's room and refusing to provide a telephone upon request. This action was taken at the insistence of a family member who did not want the resident to communicate with other family members. Interviews with staff, including the DON and Administrator, confirmed that the facility complied with the family member's request despite having the ability to provide private communication. Staff also reported being instructed not to provide a phone to the resident, and documentation in the resident's records indicated the phone was removed per family request. The resident in question was admitted following a serious vehicle collision and was in the process of recovery. Although family members claimed the resident had dementia and 'Sun Downers,' the resident's personal physician stated there was no diagnosis of dementia and that any mental deficiency would likely be temporary and related to the accident. The resident was able to communicate clearly, recall events accurately, and was listed as his own responsible party in admission records. The resident repeatedly requested access to a phone to contact his wife and daughter but was denied each time, with staff confirming these requests and their instructions to refuse them. Facility policies reviewed during the investigation stated that residents have the right to self-determination and access to communication, including telephones. The Medical Power of Attorney provided by the family only took effect if the resident was deemed unable to make decisions by a physician, which was not the case. Despite this, the facility prioritized the family member's demands over the resident's rights, resulting in the removal of communication access without appropriate legal or medical justification.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to them. During an observation, Medication Cart #1 was found unlocked and unattended in the 300 Hall, outside a resident's room and across from the nurses' station, with no staff present in the immediate area. Medication Tech A, who was responsible for two medication carts that day, admitted to forgetting to lock the cart when switching between carts. The Director of Nursing (DON) confirmed the cart was found unlocked and was unsure who was responsible until Medication Tech A acknowledged it was her oversight. Interviews revealed that Medication Tech A was trained to always lock medication carts and recognized the risk of leaving them unlocked, stating that a patient could access the medications. The Administrator confirmed that staff routinely receive in-services on medication administration and the importance of keeping medication carts locked. Despite requests, the facility's policy on locked medication carts was not provided during the survey.
Failure to Ensure Timely Response to Incoming Calls and Maintain Functioning Communication Devices
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to maintain the highest practicable psychosocial well-being for 17 residents, specifically by not ensuring that calls directed to a centralized staff work area were answered and that portable phones were available and functioning. Multiple observations and interviews revealed that after hours, incoming calls to the facility were routed to nurses' stations, but staff did not consistently answer these calls. A confidential interview indicated that a resident's representative was unable to reach staff by phone on several occasions, particularly during early morning hours, to discuss concerns about the resident's care. Surveyor observations confirmed that calls to the facility went unanswered at certain times, and portable phones at the 200 hall nurses' station were missing or not functioning for an extended period. Further interviews with staff, including the receptionist, ADON, DON, and ADM, confirmed that portable phones were either misplaced or not properly charged, and that staff were expected to answer calls after hours using either land lines or portable phones. The DON and ADM acknowledged that the portable phone at the 200 hall had been missing for months and that callers could not leave messages unless they knew a direct extension. The facility's resident rights policy emphasized the importance of communication and access, but the lack of functioning phones and unanswered calls directly impacted residents' ability to communicate with the facility.
Failure to Provide Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for the resident council meetings, resulting in repeated interruptions by staff and providers during the meetings. Observations showed that the meetings were held in the activities room, which is an open area without doors, allowing staff to enter and disrupt the proceedings. During one observed meeting, five care staff and providers entered the room, interrupting the group. Residents reported that staff frequently came in and out of the activities room during meetings and used the vending machines located there. Interviews with facility leadership confirmed that resident council meetings were typically held in the activities room or dining room, and that the conference room, which is a private area, was unavailable because it was used as a workspace by nurse managers. The classroom was only available if not in use for orientation. The facility's Resident Rights policy states that residents are entitled to privacy and confidentiality, but the current practice did not ensure these rights during resident council meetings.
Failure to Ensure Correct Negative Pressure Wound Device Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards for a resident with pressure ulcers, specifically regarding the use of a negative pressure wound device. The resident, an elderly female with diagnoses including heart failure, pyelonephritis, and dementia, was admitted with two stage IV pressure ulcers. Physician orders specified that the negative pressure wound device should be set to 125 mmHg. However, on two consecutive days, observations revealed the device was set at 150 mmHg instead of the ordered setting. The resident was unaware of the correct settings or when they were last changed. Interviews with nursing staff indicated a lack of clarity and oversight regarding the correct device settings. The nurse assigned to the resident was uncertain about the required settings and deferred to the treatment nurse, who then acknowledged the discrepancy and adjusted the device to the correct setting. The DON stated that it was the responsibility of the treatment nurse to ensure the settings matched physician orders and characterized incorrect settings as a medication error. Facility policy also required verification of physician orders and correct device settings, which was not followed in this instance.
Failure to Follow Food Storage and Safety Standards in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and safety standards. Specifically, foods stored in the refrigerator, such as trays of drinks and fruit cups, were found to be unlabeled and undated. In the dry storage area, an opened jug of mashed potatoes was left exposed to air, and a can of marinara sauce was found to be dented. Additionally, open items in dry storage were not properly sealed, and dented cans were not separated from other food items as required. Interviews with dietary staff and management confirmed that it was the responsibility of kitchen aides and all kitchen staff to ensure food and drinks were labeled, dated, and sealed appropriately, and to check for and separate dented cans. Staff acknowledged that failure to follow these procedures could result in residents being served expired or contaminated food and drinks. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Failure to Provide Timely Call Light Response and Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received necessary assistance with grooming and timely response to call lights. Record review showed that the resident, a female with multiple diagnoses including muscle weakness, gait abnormalities, lack of coordination, cognitive communication deficit, and end stage renal disease, required significant assistance. Interviews and documentation revealed that the resident experienced delays in care, specifically after a bowel movement when staff turned off her call light without providing the requested assistance, resulting in her remaining unclean until the following morning. Additional interviews with CNAs confirmed that call lights were sometimes turned off without care being provided, and residents expressed reluctance to use the call light due to fear of being ignored or inconveniencing staff. Staff interviews further indicated that call light response times were inconsistent, with some staff acknowledging that lights could remain unanswered for up to 15 minutes or more. The DON and Administrator confirmed that residents had complained about delayed responses and that there was no overnight manager on duty, relying instead on periodic spot checks by leadership. Review of grievance reports and facility policy corroborated that the expectation was for call lights to be answered as soon as possible, but this standard was not consistently met, resulting in unmet care needs for the resident.
Failure to Sanitize Equipment and Perform Hand Hygiene Between Resident Contacts
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by observations of a medication aide (MA G) not sanitizing a blood pressure cuff and not performing hand hygiene before resident contact. Specifically, MA G obtained a blood pressure device from an unattended medication cart and used it on a male resident with encephalopathy, cerebral infarction, pneumonia, and diabetes mellitus type II, without sanitizing the cuff or device prior to use. Later, MA G used the same device on a female resident admitted for extended rehabilitative therapy following a femur fracture and with diabetes mellitus type II, again failing to sanitize the equipment and also neglecting to perform hand hygiene before resident contact. Interviews with MA G revealed she did not recall performing hand hygiene before contact with the second resident and assumed the blood pressure cuff was sanitized before use, later acknowledging that she should have sanitized it between uses. Both the Director of Nursing (DON) and the Administrator confirmed their expectations that staff perform hand hygiene and sanitize shared equipment between resident contacts, in accordance with facility policies and in-service training records, which MA G had attended. Facility policies reviewed emphasized the importance of hand hygiene before and after resident contact and the cleaning and disinfection of reusable resident-care equipment between uses.
Failure to Ensure Safe Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable well-being of a resident who was discharged home. The Administrator (ADM) and Director of Nursing (DON) directed staff to discharge a resident with a diagnosis of dementia, confusion, and altered mental status, who had no power of attorney (POA), to her home without confirming appropriate supervision or care arrangements. The Interdisciplinary Team (IDT) did not notify the nurse practitioner (NP) or physician (MD) about the resident's discharge home alone and without services. The discharge planning process did not include a thorough assessment of the resident's cognitive and functional abilities at the time of discharge, and the discharge Minimum Data Set (MDS) was incomplete and unsigned by authorized personnel. The resident's care plan indicated she required assistance with activities of daily living (ADLs), supervision for mobility and transfers, and was at risk for falls due to her cognitive impairment. Despite these documented needs, the resident was discharged via a ride-share service to an apartment that, according to family, lacked electricity and was unsanitary. The family member who was listed as an emergency contact expressed concerns about the resident's ability to live alone and the unsafe home environment, but these concerns were not adequately addressed by the facility. The facility did not ensure that home health services or necessary durable medical equipment were arranged prior to discharge, and other potential family contacts were not involved in the discharge planning process. Interviews with facility staff and family revealed that the discharge was driven by the end of the resident's insurance coverage, and the ADM did not investigate the home environment or seek alternative family support before proceeding. The resident arrived home without a walker or wheelchair and was left alone, with the family member only able to assist after the fact. The NP later confirmed that the resident's confusion was progressive and that she required supervision if discharged home. The facility's actions resulted in the resident being returned to an unsafe environment without adequate planning or support, as documented by multiple staff and family interviews.
Removal Plan
- Residents and family members will be instructed to provide their own transportation upon discharge. Courtesy transportation will no longer be provided.
- Discharge paperwork will be presented to the power of attorney, responsible party, and/or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge.
- A discharge summary/plan of care will be provided to the cognitively intact resident, responsible party, and/or power of attorney.
- Post discharge services such as home health will be set up prior to discharge.
- Physicians and NPs will be notified of discharges to address resident's needs.
- An in-service will be completed with the Administrator by the Regional President of Operations that details the entire discharge planning process including the completion of discharge summaries, contacting RP/POA's, confirmation of transportation, and home health set up confirmation.
- An in-service will be completed with the Social Worker and Case Manager by the Administrator that details the entire discharge planning process including the completion of discharge summaries, contacting RP/POA's, confirmation of transportation, and home health set up confirmation.
- An in-service will be completed with the IDT by the Administrator regarding the completion of the discharge summary, notifying the Physicians and NPs of discharges to address resident's needs, providing discharge paperwork to the power of attorney, responsible party, and/or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge.
- All discharges will be reviewed by the IDT in a weekly standards of care meeting to ensure care/summary was completed, Discharge Summary completed, signatures on the discharge summary by the appropriate party, confirmation of home health orders, and means of discharge transportation were completed.
- All residents that are not cognitively intact and do not have a Power of Attorney or Responsible Party at the time of discharge, the facility social worker and/or administrator will contact the ombudsmen and seek assistance if needed for guardianship.
- The DON/Designee will review all discharge orders for upcoming discharges for completion.
- The DON/Designee will communicate with the NP/Physician prior to discharge to address any additional post discharge needs.
- The Administrator/Designee will audit all discharges for discharge summaries, discharge location, means of transportation, and confirmation of home health.
- A Quality Assurance and Performance Improvement review of the removal plan will be completed with the Medical Director for agreement with this plan.
Failure to Include Discharge Planning in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans that included measurable objectives and timeframes for four out of ten residents reviewed. Specifically, the care plans did not address discharge goals, objectives, and interventions for these residents, despite their varied and complex medical conditions. For example, one resident with acute kidney failure, dementia, and impaired mobility had a care plan that omitted discharge planning, even though she was moderately cognitively impaired and unable to recall details about her discharge or personal belongings. Another resident, admitted for short-term skilled care following hospitalization, had diagnoses including muscle wasting, prostate cancer, and cardiac issues. Although he was cognitively intact and aware of his short-term therapy goals, his care plan did not include discharge objectives or interventions. Similarly, two other residents with significant medical histories, such as end-stage renal disease, COPD, stroke, and hemiparesis, also had care plans lacking discharge planning components, despite their imminent plans to return home with family support. Interviews with facility staff, including the ADON, DON, and ADM, confirmed that care plans were not consistently updated to reflect discharge planning, with some staff relying on separate discharge assessments or planning by other disciplines. The facility was unable to provide a care plan policy when requested. Federal guidelines require that comprehensive care plans include measurable objectives, timeframes, and discharge planning in consultation with the resident and their representatives, which was not met in these cases.
Failure to Complete Significant Change Assessment After Resident's Cognitive Decline
Penalty
Summary
The facility failed to ensure that a resident who experienced a significant change in condition was comprehensively assessed within 14 days, as required. Specifically, a female resident with a history of unspecified dementia and cognitive communication deficit was readmitted to the facility and observed with increased confusion, memory loss, and altered mental status. Despite these changes, which included a decline in cognitive function and increased need for assistance with activities of daily living (ADLs), a Significant Change in Status Assessment (SCSA) was not completed. Medical records and staff interviews confirmed that the resident's cognitive status had deteriorated during her stay, with documentation of progressive dementia and acute metabolic encephalopathy. The care plan and progress notes reflected the resident's need for increased supervision and support, and staff interviews indicated that the resident required more assistance and should not have been discharged home alone. The facility's policy and CMS regulations require that significant changes in a resident's condition, especially those impacting multiple areas of health status and requiring interdisciplinary review, trigger a comprehensive assessment. Interviews with the Assistant Directors of Nursing (ADON), Nurse Practitioner (NP), and MDS nurse revealed that the expectation was for a Significant Change Assessment to be completed when a resident exhibited altered mental status or cognitive decline. The MDS nurse and DON acknowledged that the assessment was not completed as required, and that the failure could result in the resident's plan of care not being updated to reflect her current needs.
Failure in Pain Management for Resident After Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident who experienced severe breakthrough pain following an unwitnessed fall. The resident, who had a history of Type 2 Diabetes, Essential Hypertension, Dementia, Heart Failure, and a past pelvic fracture, was found on the floor of his room, expressing pain through yelling and grabbing his right hip. Despite the resident's evident distress, there were no documented pain assessments on the days following the fall, and the resident's care plan from a previous admission was not updated to reflect his current condition. The resident's physician had ordered Tramadol and Tylenol for pain management, but there was a delay in administering these medications. The Tramadol was never delivered, and the Tylenol was not documented as given until later in the day. The resident's family, upon visiting, found him in severe pain and requested he be sent to the emergency room, where he was diagnosed with a right hip fracture requiring surgery. Interviews with facility staff revealed communication lapses and a lack of timely intervention, with the nurse responsible for the resident's care failing to complete necessary pain assessments and neuro checks. The facility's Director of Nursing (DON) and other staff were not fully aware of the resident's condition and the lack of pain management until after the incident. The nurse practitioner was contacted for pain medication orders, but there was confusion and delay in obtaining and administering the necessary medications. The facility's failure to adequately assess and treat the resident's pain placed him at risk for unnecessary pain and discomfort, highlighting significant deficiencies in the facility's pain management practices.
Failure to Provide Adequate Post-Fall Care and Pain Management
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who experienced a fall, resulting in a deficiency. The resident, a male with a history of Type 2 Diabetes, Essential Hypertension, Dementia, Heart Failure, and a History of Falling, was found on the floor of his room. Despite expressing pain through yelling and grabbing his right hip, routine neuro checks were not completed following the fall. The resident's care plan, which included goals for pain management, was not adhered to, as there were no documented pain assessments on the days surrounding the incident. The resident's physician's orders included pain management medications such as Tramadol and Tylenol, with instructions to monitor pain every shift. However, these orders were not effectively followed, as evidenced by the lack of documented pain assessments and the delayed administration of pain medication. The resident continued to experience pain, leading to a family request for emergency medical attention. The resident was eventually diagnosed with a right hip fracture requiring surgery. Interviews with facility staff revealed a breakdown in communication and documentation. The LVN responsible for the resident's care admitted to not completing neuro checks, believing the resident's condition had improved. The DON and Administrator acknowledged the failure to follow up on neuro checks and pain assessments, which contributed to the resident's prolonged suffering. The facility's policies on incident reporting and investigation were not adequately implemented, resulting in the deficiency.
Failure to Document Medication and Assessments After Resident Fall
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who experienced a fall. The resident, a male with a history of Type 2 Diabetes, Essential Hypertension, Dementia, Heart Failure, and a History of Falling, did not have the administration of Tylenol Arthritis 650 MG documented on the Medication Administration Record during the morning shift. Additionally, the time of administration was not recorded in the progress notes. This lack of documentation was attributed to LVN A, who also failed to conduct and document necessary pain assessments and neuro checks following the resident's fall. On the morning of the fall, the resident was found on the floor, expressing pain and grabbing his right hip. Despite these signs, LVN A did not complete neuro checks or pain assessments throughout her shift, as the resident's vocal expressions of pain decreased. The resident's wife indicated that Tylenol could be administered for relief, which LVN A did, but failed to document it properly. The incident report was not completed until two days later, which delayed the necessary follow-up assessments and documentation. Interviews with the Director of Nursing (DON) and the Administrator confirmed that LVN A did not adhere to the facility's documentation policies. The DON emphasized the importance of timely and accurate documentation to prevent risks such as state visits or legal actions. The Administrator noted that the lack of documentation compromised the resident's assessment and care. The facility's policies on pain assessment and management, as well as medication administration, were not followed, leading to this deficiency.
Failure to Notify Family of Resident's Fall and Injury
Penalty
Summary
The facility failed to immediately notify the family member of a significant change in a resident's health status following an unwitnessed fall. The resident, a male with a history of Type 2 Diabetes, Essential Hypertension, Dementia, Heart Failure, and a History of Falling, experienced breakthrough pain after the fall. Despite the resident's evident distress and pain, the family was not informed of the incident until they arrived at the facility later that morning. The progress notes indicate that the resident was found on the floor of his room, expressing pain and grabbing his right hip. Although the nurse practitioner and the Director of Nursing (DON) were notified, the family was not informed by LVN A, who was responsible for the resident's care at the time. The family only became aware of the fall when they visited the facility and noticed the resident's condition. The family member requested the resident be sent to the emergency room due to the pain, leading to a diagnosis of a right hip fracture requiring surgery. Interviews with facility staff, including LVN A, the DON, and the Administrator, confirmed that the family was not notified as per the facility's policy. LVN A admitted to failing to inform the family, and the DON acknowledged that all staff were trained to notify the doctor, nurse management, and the family after a significant change or incident. The failure to notify the family promptly placed the resident at risk of not having an advocate and potentially delayed medical treatment.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call button was accessible, which is a critical intervention to prevent falls. On multiple occasions, the call light for a resident with a history of falls, mild cognitive impairment, and generalized muscle weakness was not within reach. Observations on the specified date revealed that the call light was placed in various inaccessible locations, such as across the room or behind the resident, making it impossible for the resident to use it to call for assistance. Interviews with staff, including the Director of Nursing (DON), Registered Nurse (RN), Licensed Vocational Nurse (LVN), and Certified Nursing Assistants (CNAs), confirmed that the expectation was for call lights to be within reach at all times. Despite this, the resident's call light was repeatedly found out of reach, and staff acknowledged the importance of having the call light accessible to prevent falls. The facility's policy on answering call lights also emphasized the need for call lights to be within easy reach of residents, highlighting a failure to adhere to established procedures.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, specifically in the storage, preparation, distribution, and serving of food. During an observation in the walk-in freezer, it was found that there were two open cases of food, including frozen cookies and hamburger patties, with interior plastic bags left open. This exposed the food to ambient air, potential contaminants, freezer burn, and a decrease in quality. Additionally, a coil of sausage was found without any covering or packaging, in direct contact with a metal shelf. None of these food items were labeled or dated, which is against the facility's policy. The Dietary Manager confirmed that the facility's policy requires all food to be sealed, labeled, and dated with the received or open date and expiration or best use by date. The manager acknowledged that the food items in question were not properly sealed, labeled, or dated, which is her responsibility. The facility's policy, HSG Policy 017, and the U.S. FDA Food Code both emphasize the importance of protecting food from contamination by ensuring it is stored in packages, covered containers, or wrappings, and labeled and dated appropriately.
Inadequate Hand Hygiene by CNA During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA A, who did not perform hand hygiene after direct contact with residents while serving meals. Specifically, CNA A was observed serving lunch trays to four residents without using hand sanitizer or washing hands between each resident interaction. This lapse in protocol occurred despite the availability of hand sanitizer in the hallway and the CNA's prior training on hand hygiene procedures. The residents involved in this deficiency included a female resident with atrial fibrillation, hypertension, and diabetes, a male resident with dementia, hypertension, and diabetes, another male resident with a history of stroke, heart failure, and diabetes, and a male resident with hypertension, depression, and hypothyroidism. These residents required assistance with activities of daily living and had varying levels of cognitive impairment. The Director of Nursing confirmed that all staff were required to perform hand hygiene after resident contact to prevent the spread of infections.
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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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