Morningside Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 602 Babcock Rd, San Antonio, Texas 78201
- CMS Provider Number
- 455523
- Inspections on file
- 25
- Latest survey
- April 11, 2026
- Citations (last 12 mo.)
- 25 (2 serious)
Citation history
Health deficiencies cited at Morningside Manor during CMS and state inspections, most recent first.
A resident with multiple comorbidities and severe cognitive impairment reported to hospital staff that she felt staff at the facility might be neglecting her due to differing political views, leading the facility’s former Executive Director to self-report the allegation to HHSC. Despite email communications indicating that an investigation report was being prepared and a request from HHSC’s Complaint and Incident division to submit that report, neither HHSC’s TULIP system nor the facility’s records contained a 3613A Provider Investigation Report or other complete written investigation. The current ED and DON could only locate emails, in-services, and resident safety surveys, and an encrypted email that could not be opened, demonstrating that the facility did not maintain evidence of a thorough investigation or timely written report as required by its Abuse Prevention Program policy.
A resident with spinal stenosis, diabetes, anemia, and hypertension had an annual MDS completed showing no cognitive impairment, but no subsequent MDS was submitted within the required quarterly timeframe. The MDS LVN, who relied on the EHR-generated schedule, acknowledged missing the quarterly MDS that was due, while the DON confirmed the due date and could not explain the omission. The Executive Director, who reported weekly MDS audits, verified that the next assessment should have been completed but was not, contrary to facility policy requiring quarterly MDS completion within 92 days of the prior comprehensive assessment.
The facility failed to maintain comprehensive care plans for several residents, leading to discrepancies in prescribed care. A resident with dysphagia received incorrect liquid consistency, risking aspiration. Other residents lacked documentation for necessary assistive devices and interventions, such as bed rails and catheter care. These omissions highlight significant oversights in ensuring accurate and updated care plans.
The facility failed to ensure no more than 14 hours between the evening meal and breakfast unless a bedtime snack was provided, affecting three out of nine residents reviewed. Staff interviews revealed that snacks were not routinely offered, and residents were unaware of available options. Snacks were only provided upon request, and the Director of Culinary Services confirmed that only a dialysis snack list was maintained.
The facility failed to store and cover food properly in the kitchen, with boxes stored less than 18 inches from the ceiling and uncovered chocolate pies in the walk-in refrigerator. The CDM acknowledged these issues, which violated the facility's food storage policy.
A resident was left without access to a call light after being assisted to her room by a CNA, leading to her loudly calling for help. The resident, who had impaired vision and hearing, was positioned away from her call light, which was not within reach. The DON confirmed that call lights should be accessible to residents, in line with CMS regulations.
A resident with a history of stroke returned to the facility with new diagnoses requiring neuro checks every four hours. The facility failed to perform three out of seven required checks and did not notify the physician, despite worsening symptoms. The family declined checks while the resident was asleep, and staff did not report the missed assessments, leading to a deficiency finding.
A resident with a history of major depressive disorder and other conditions was unable to report grievances effectively due to a failure by the facility staff. The resident was found calling out for assistance with her call light out of reach, and her complaints about being left unattended and receiving rushed care were not documented or reported by the CNA. The facility's grievance policy was not followed, as the Administrator was unaware of the resident's grievance, indicating a failure to ensure residents could voice grievances without fear of reprisal.
A facility failed to conduct ordered neuro-checks for a resident with a history of stroke, due to the resident being asleep and family refusal. The nursing staff did not notify the physician or nurse practitioner of these missed assessments, assuming the family was aware of the potential consequences. The resident was later sent to the hospital with a diagnosis of cerebral infarction and hemiparesis. This deficiency was identified as an Immediate Jeopardy, which was later removed, but the facility remained out of compliance.
A facility failed to ensure proper pharmaceutical services when an LVN dispensed and stored a resident's medications in a pill cup for later administration, instead of disposing and re-dispensing them when the resident became available. The resident, with conditions such as hypertension and diabetes, was prescribed multiple medications to be administered daily. This action was against the facility's policy, which mandates that medications be stored in their original packaging.
A resident with dysphagia was provided nectar thickened liquids without a physician's order, contrary to the prescribed pureed diet with thin liquids. The family was responsible for thickening the liquids, as the kitchen did not prepare them to the required consistency. This practice did not align with the facility's policy, resulting in a deficiency.
Two residents with diabetes did not have orders or care plans for diabetic shoes in their records, despite assessments indicating a need. The facility failed to document or communicate the provision of diabetic shoes, leading to a lack of awareness among staff about the delivery and necessity of these assistive devices.
Failure to Complete and Submit Required Investigation Report for Alleged Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of neglect involving Resident #1 was thoroughly investigated and reported to HHSC as required by the facility’s Abuse Prevention Program policy. Resident #1 was an elderly female with diabetes, anemia, vascular dementia, cerebral infarction, and hypertension, with documented short- and long-term memory problems and severely impaired cognitive skills for daily decision-making. Her care plan noted altered mood and behavior, including being easily annoyed, making racist and false accusations, refusing psychiatric services, and refusing certain staff based on political views, with an intervention to allow her to verbalize emotions and validate her feelings. The incident began when a hospital case manager informed the facility’s Marketing Liaison that Resident #1 had expressed uncertainty about returning to the facility because she felt staff might be neglecting her due to differing political views. This concern was relayed to the then-Executive Director (Executive Director A), who self-reported the allegation to HHSC as Intake #1028885. During a later interview, Resident #1 stated that staff were not listening to her, but when asked for clarification, she focused on missing television channels and did not provide specific examples, individuals, or further details about neglect. The DON reported that the hospital also filed a complaint involving Resident #1 that was investigated by the survey team, and that Executive Director A had asked an HHSC surveyor whether an investigation report was needed for Intake #1028885. Record review showed that no 3613A Provider Investigation Report for Intake #1028885 was found in TULIP, and facility staff, including the current Executive Director (Executive Director B) and the DON, were unable to locate a completed investigation report in the facility’s records. Emails showed that Executive Director A told an HHSC surveyor she was working on the investigation report and later asked if she should proceed with submitting it after being told by the survey team that a 5-day investigation was not required, while also receiving a request from the HHSC Complaint and Incident division to submit the investigation. An encrypted email from HHSC to Executive Director A and an encrypted email from Executive Director A to HHSC were identified, but the facility did not have the password and could not access any attached report. The facility’s Abuse Prevention Program policy required that an investigation be initiated and a written report of the investigation be sent to HHSC no later than the fifth calendar day after the oral report, but there was no evidence that a complete written investigation report for this allegation was submitted or maintained by the facility.
Overdue Quarterly MDS Assessment for One Resident
Penalty
Summary
The facility failed to complete a required quarterly MDS assessment within the mandated three-month timeframe for one resident. The resident was an adult female admitted with diagnoses including spinal stenosis, diabetes, anemia, and hypertension. Her most recent comprehensive/annual MDS assessment was completed on 12/04/2025 and showed no cognitive impairment, with a BIMS score of 14/15. Review of the electronic health record under the MDS tab showed no subsequent MDS assessment had been submitted after 12/04/2025, and the next quarterly MDS assessment, with an ARD due by 03/06/2026, was 22 days overdue at the time of review. In interviews, the MDS LVN stated he relied on the electronic health record schedule to complete residents’ MDS assessments and acknowledged that the quarterly MDS for this resident, due on 03/06/2026, had been missed. The DON confirmed that the MDS LVN was responsible for completing MDS assessments and that she reviewed them for accuracy, and she verified that the last MDS was the annual assessment on 12/04/2025 with the next one due in March 2026, but could not explain why it was not completed. The Executive Director stated that resident MDS assessments were audited weekly and, upon reviewing the record, confirmed that the annual MDS was completed on 12/04/2025 and that the next assessment should have been completed in March 2026. The facility’s policy on MDS 3.0 Completion, dated 2025, specified that quarterly assessments must be completed using an ARD no more than 92 days from the most recent prior quarterly or comprehensive assessment, which was not followed in this case.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in meeting their medical, nursing, and psychosocial needs. Resident #6, who has a history of dementia, traumatic brain injury, and dysphagia, was given nectar thick liquids instead of the prescribed honey consistency liquids, as per the doctor's order. This discrepancy in the care plan could potentially lead to serious health risks, such as aspiration pneumonia, as noted by the speech therapist. The care plan for Resident #6 had not been updated since 2021, despite a change in dietary requirements in 2022. Resident #3, who suffers from polyneuropathy, heart failure, and dementia, did not have her 1/4 bed rails included in her care plan, despite a physician's order for their use to assist with bed mobility. Similarly, Resident #38, who has an indwelling catheter due to urine retention, did not have any interventions related to the catheter documented in her care plan. The Director of Nursing acknowledged the absence of these interventions, which are crucial for the resident's care and monitoring. Additionally, Residents #57 and #120, both of whom require 1/4 bed rails for assistance, did not have these devices included in their care plans. Resident #56, who has a history of alcoholic cirrhosis and major depressive disorder, did not have his dentures mentioned in his care plan, despite ongoing dental treatment. The facility's failure to update and maintain accurate care plans for these residents indicates a significant oversight in ensuring that all necessary interventions and assistive devices are documented and communicated to the care staff.
Failure to Provide Timely Snacks Between Meals
Penalty
Summary
The facility failed to ensure that there were no more than 14 hours between the evening meal and breakfast the following day, unless a nourishing snack was provided at bedtime, which could extend the time to 16 hours if agreed upon by a resident group. This deficiency was identified for three out of nine residents reviewed for meal frequency. The facility did not offer bedtime snacks as required, leading to extended periods between meals, which could potentially affect all residents by increasing the risk of unplanned weight loss, medication side effects, and diminished quality of life. Interviews with staff and residents revealed that residents were not made aware of available snack options, and snacks were not routinely offered. Staff members indicated that snacks were available in the nursing station refrigerator, but they were only provided if residents specifically requested them. The Director of Culinary Services confirmed that only a dialysis snack list was maintained, and no other snacks were distributed from the kitchen. The facility's policies and procedures indicated that nursing staff should offer bedtime snacks, but this was not consistently practiced.
Food Storage and Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, there were approximately five cardboard boxes filled with various food products stored less than 18 inches from the ceiling in the walk-in refrigerator. Additionally, two chocolate pies were found not fully covered, with their pie crusts exposed. These observations were made during an initial tour of the kitchen with the Certified Dietary Manager (CDM), who acknowledged that the boxes should not be stored so close to the ceiling and that the pies would need to be discarded as they could not be served. The CDM was unable to identify who was responsible for these storage issues, despite staff being trained on proper food storage practices. The facility's policy on food storage, revised in February 2024, mandates that all food and supplies be stored to prevent contamination, with items stored 6 inches above the floor and 18 inches below sprinklers.
Failure to Provide Call Light Access
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodation of their needs and preferences, specifically regarding access to a call light. On June 5, 2024, a CNA assisted a resident in a wheelchair to her room and placed her out of reach of her call light, which was approximately three feet away on her bed. The resident, who had moderate hearing difficulty, impaired vision, and was dependent on assistance for daily activities, was observed loudly calling out for attention as she was unable to reach her call light. The resident expressed frustration, stating that staff rushed through care and left her without the ability to call for assistance. During an interview, the CNA admitted to positioning the resident away from her bedside due to the resident's preference but did not attempt to place the call light within reach. The Director of Nursing (DON) confirmed that call lights should be within reach of residents, except in certain situations like activities or when residents can self-ambulate. The facility's policy adheres to CMS regulations, which require that the call system be within reach and usable by residents. The deficiency was identified as a failure to accommodate the resident's needs and preferences, as outlined in the CMS's State Operations Manual.
Failure to Notify Physician of Missed Neurological Checks
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant need to alter treatment. This deficiency was identified for a resident who was hospitalized and returned with new diagnoses, including cerebral infarction, hemiplegia, hemiparesis, ataxia, and slurred speech. The resident's medical orders required neurological checks every four hours for three days, with instructions to notify the nurse practitioner of any deficits. However, the facility did not perform three out of seven required neuro checks over a 12-hour period and failed to notify the medical doctor about these missed assessments. Interviews and record reviews revealed that the resident's family had declined neuro checks while the resident was asleep, and the facility staff did not contact the nurse practitioner to report the missed checks. The resident's condition worsened, with increased speech slurring and balance issues, leading to hospitalization with a new diagnosis of cerebrovascular accident. The nurse practitioner and medical director were not informed of the missed neurological assessments until much later, which was against the facility's policy requiring notification of the attending physician in cases of treatment refusal or significant changes in condition. The facility's policy, revised in April 2009, mandates that the nurse supervisor or charge nurse notify the resident's attending physician or on-call physician when there is a refusal of treatment or medications. Despite this policy, the facility did not adhere to the required notification procedures, resulting in a deficiency that was identified during the survey. The immediate jeopardy was recognized due to the failure to follow medical orders and notify the appropriate medical personnel, which could have potentially led to harm for the resident.
Removal Plan
- Verify that current orders are being followed as prescribed by physician/NP.
- All licensed nurses will be in-serviced regarding the need to notify physician/NP of any refusals that keep us from following orders prescribed.
- Physicians/NP partners will be notified to provide team with more concise orders and to consider the nurse's feedback regarding specific resident's characteristics or preferences when deciding a plan of action.
- The DON/Designee will review 24-hour report daily for change of condition UDA including neurological checks for any refusals and review for medical provider notification.
- All residents have the potential to be affected by this alleged deficit practice. At risk resident will be identified by reviewing 24 hr. report, changes of condition assessment and neurological checks.
- Weekly the DON and/or designee will pull all orders from the EHR for any refusals and review for physician and/or NP notification. The administrator will meet with DON weekly to audit and verify this review has been completed.
- Reports to the QAPI committee regarding the reviews will be discussed with the team on an ongoing basis.
- A corporate designee will audit compliance with orders weekly until stable and monthly for the next six months, quarterly thereafter if stable and report findings to the governing body.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal, as evidenced by the case of a resident who was unable to report her complaints effectively. The resident, who had a history of major depressive disorder, glaucoma, and atherosclerosis, was observed calling out for assistance because her call light was out of reach. Despite her attempts to communicate her grievances about being left unattended and receiving rushed care, her complaints were not documented or reported by the CNA responsible for her care. The resident's care plan indicated a potential communication problem due to a hearing deficit, and it was noted that she should have her call light within reach to ensure a safe environment. However, during an observation, the resident was found in her wheelchair with the call light placed on her bed, approximately three feet away, making it inaccessible. The CNA admitted to positioning the resident away from her bedside due to the resident's preference but failed to ensure the call light was within reach, which led to the resident's frustration and vocal complaints. Interviews with the Director of Nursing and the Administrator revealed that the staff should assist residents with grievance reports, but the Administrator was unaware of the resident's grievance. The facility's grievance policy emphasized the right of residents to voice grievances without discrimination or reprisal and required prompt efforts to resolve them. However, the lack of documentation and reporting of the resident's complaints indicated a failure to adhere to this policy, potentially placing residents at risk by not addressing their grievances.
Failure to Conduct Ordered Neuro-Checks and Notify Physician
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to significantly alter treatment. This deficiency was identified for one of the eight residents reviewed for notification. The resident in question was admitted with diagnoses including dysphagia following a cerebral infarction and dementia. Upon returning to the facility from the hospital, the resident had new diagnoses, including cerebral infarction, hemiplegia, hemiparesis affecting the right dominant side, ataxia, and slurred speech. Despite these conditions, the facility did not perform neuro-checks as ordered every four hours for three days. The nursing staff failed to conduct the required neuro-checks due to the resident being asleep and family refusal. There was no documentation of the physician or nurse practitioner being notified of these missed assessments. Interviews with the nursing staff revealed that they did not explain the potential consequences of not performing the neuro-checks to the family, assuming the family was already aware due to the resident's history of strokes. The nurses did not attempt to reassess the resident until the next scheduled interval, and there was no communication with the medical provider about the refusals. The resident was eventually sent to the hospital and diagnosed with cerebral infarction and hemiparesis. The failure to perform the ordered assessments and notify the medical provider of refusals could have resulted in the resident not receiving necessary care, potentially leading to a decline in health. This deficiency was identified as an Immediate Jeopardy, which was later removed, but the facility remained out of compliance due to the need to monitor and evaluate the effectiveness of corrective actions.
Removal Plan
- Verify that all assessments were being followed as ordered by physician/NP.
- All licensed nurses will be in-serviced regarding the need to notify physician/NP immediately of any refusals that keep us from following physician ordered assessments. Licensed Nurses on vacation, leave, or unavailable will be trained prior to their next scheduled shift. A Licensed Nurse roster is being utilized to track the Licensed Nurses who have responded and have been in-serviced. The identified Licensed Nurses who were unavailable will attempt to be reached by phone call, text message, and email by the DON/Designee. The DON/Designee will work with the scheduler and audit daily to ensure any Licensed Nurse will not be scheduled until the necessary in-service has occurred.
- The DON/Designee will review 24-hour report daily for change of condition UDA including neurological checks for any refusals and review for medical provider notification. The Weekend Nurse Manager/Designee will review any refusals and contact the DON/Designee immediately if a resident has a refusal to ensure the medical provider has been notified. Audits will be completed daily, weekly, monthly, and periodically thereafter.
- All residents have the potential to be affected by this alleged deficient practice. At risk residents will be identified by reviewing 24-hour report, changes of condition assessment and neurological checks.
- Weekly the DON and/or designee will pull all orders from the EHR for any refusals and review for physician and/or NP notification. The administrator will meet with the DON weekly to audit and verify this review has been completed.
- Reports to the QAPI committee regarding the reviews will be discussed with the team on an ongoing basis.
- A corporate designee will audit compliance with orders weekly until stable and monthly, quarterly thereafter if stable and report findings to the governing body.
Failure in Medication Dispensing and Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate dispensing and administering of medications for a resident. LVN U dispensed 11 pills for a resident and stored them in a small pill cup in the medication cart with the intention of administering them later. This occurred because the resident was unavailable at the time, being in the shower. Instead of disposing of the medications and re-dispensing them when the resident became available, LVN U continued to dispense and administer medications for other residents. The resident involved was a male with diagnoses including hypertension, diabetes type II, and hyperlipidemia, and was assessed with no cognitive impairment. The medications prescribed for daily administration at 8:00 AM included Amlodipine, Aspirin, Fish oil, Lisinopril, Multivitamin, Sertraline, Vitamin C, Donepezil, Gabapentin, Hydralazine, and Sennosides-Docusate Sodium. The facility's policy requires that drugs and biologicals be stored in their original packaging and not transferred between containers by nursing staff, which was not adhered to in this instance.
Failure to Ensure Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a therapeutic diet was prescribed by the attending physician for a resident with dysphagia following a cerebral infarction. The resident was admitted with diagnoses including dysphagia and mild protein-calorie malnutrition. The physician's orders indicated a pureed diet with thin liquids, but the resident was provided with nectar thickened liquids instead. This discrepancy was not supported by a physician's order, and the family was responsible for thickening the liquids, which was not in accordance with the facility's policy. Interviews with staff and family members revealed that the kitchen did not thicken liquids to nectar consistency due to concerns about the liquids becoming too thick by the time they reached the resident. Instead, thickening packets were provided for the nursing staff to use at the time of serving. The facility's policy required that thickened liquids be available as specified in the physician's orders, but this was not followed, leading to a deficiency in the care provided to the resident.
Lack of Documentation for Diabetic Shoes
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding the provision of diabetic shoes for two residents. Resident #25, who was admitted with a diagnosis of Diabetes Mellitus, did not have an order or care plan for diabetic shoes in her medical record, despite having a history of poor circulation. Similarly, Resident #57, who also had a diagnosis of Diabetes Mellitus and a history of pre-ulcerative callus, lacked an order or care plan for diabetic shoes in her record. Both residents expressed concerns about not receiving their diabetic shoes, which they had been expecting for several weeks. The deficiency was further highlighted by the lack of communication and documentation within the facility. The Social Worker arranged for a company to provide free diabetic shoes to residents with diabetes, but this was not communicated to the Director of Nursing (DON) or the Administrator (ADM). The shoe company representative confirmed that they had assessed residents and obtained physician orders, but these were not reflected in the facility's records. The ADM and DON were unaware of the delivery of diabetic shoes and acknowledged the absence of a policy regarding diabetic shoes or durable medical equipment (DME) for residents.
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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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