Normandy Terrace Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 841 Rice Rd, San Antonio, Texas 78220
- CMS Provider Number
- 675823
- Inspections on file
- 52
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 35 (1 serious)
Citation history
Health deficiencies cited at Normandy Terrace Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified that the facility did not obtain required signed consents or adequately ensure resident/responsible party participation for psychotropic medications for two residents with severe cognitive deficits and multiple psychiatric diagnoses. One resident received Ativan, Oxcarbazepine, and Nuplazid for agitation and psychosis without signed consents for two antipsychotics, despite being care planned for psychotropic use and having severe cognitive impairment. Another resident with dementia, depression, anxiety, and behaviors was observed drowsy and slurring speech while on scheduled and PRN Ativan, and the responsible party reported the drug calmed behavior but caused drowsiness; however, no signed consent for the antipsychotic medication was found. The DON stated that EHR-generated consents were sufficient and that signed consents were not needed for Ativan used for anxiety, even though the facility’s psychotropic policy and the EHR consent form instructions required a printed, resident/RP-signed consent for each psychoactive medication.
A resident with COPD and other comorbidities, who had PRN orders for oxygen and albuterol nebulizer treatments and a care plan addressing respiratory needs, was observed sitting in a wheelchair while an unprotected nebulizer face mask and tubing lay on the bedside table attached to a nebulizer machine, with no storage receptacle in the room. The resident confirmed the mask was for COPD treatment. An LVN stated the equipment was newly replaced after room cleaning but had not yet been bagged. The DON, MA, and RN all reported that respiratory tubing, nasal cannulas, and masks should always be bagged when not in use or replaced if left unbagged, yet the facility’s oxygen policy only addressed changing tubing when malfunctioning or visibly contaminated and did not address storage of respiratory equipment.
A resident with dementia, prior stroke, COPD, and a healing wrist fracture, who was independent with mobility but had documented impaired cognition and agitation, left the building unsupervised by activating a keypad-controlled front door and walking to a nearby fast-food restaurant. Earlier that evening, the resident had expressed anger about being assigned a roommate and received medications from an LPN, after which she was assisted by CNAs to the shower and then back toward her room. Video showed the resident later walking alone from her hall, through the dining area, to the lobby and exiting via the coded door without staff intervention, while a roommate reported that staff typically did not check on her after the last med pass. EMS notified the facility after finding the resident off-site, and the resident appeared confused and did not recognize the LPN when located, demonstrating a failure to keep the environment free of accident hazards and to provide adequate supervision to prevent elopement.
A resident with type 1 DM and on renal dialysis had an ordered insulin Lispro pen that was found by surveyors sitting on top of a medication cart instead of being secured inside the locked cart. An LVN reported she had used the pen earlier in the day and dated the cap but could not recall if she had locked it afterward, and believed it might have been left by a previous shift. The DON stated that all medications, including insulin, must be locked immediately after use and accessible only to authorized staff, consistent with the facility’s medication storage policy.
A resident with diabetes, impaired mobility, and risk for skin breakdown had a physician’s order and MAR entry for daily TRIAD application to the buttocks for wound healing, but the TAR lacked documentation of this treatment on multiple days. The resident reported receiving the cream every morning and acknowledged refusing some medications but not this treatment. The ADON, DON, and an LVN stated that all medications and treatments, including refusals, must be documented on the MAR/TAR with no blanks, and facility policy required complete and accurate documentation on medication sheets. Despite these expectations, the TAR contained blank entries for the ordered wound treatment, resulting in incomplete clinical records.
Surveyors found that call lights were not kept within reach for three residents with significant cognitive and physical impairments, despite care plan interventions and facility expectations requiring accessible call systems. One resident with dementia and osteoarthritis had a call light wrapped on the wall behind the bed, out of reach, even though staff acknowledged she used it and that it should be clipped to the bed. Another resident with a neurocognitive disorder and anxiety had a call light under the bed against the wall while asleep and unrousable, and CNAs confirmed it had been out of reach despite care plan directions to use a bell or call light for assistance. A third non-verbal resident with cerebral palsy and severe intellectual disability had a call light hooked on the wall past the footboard, and an LPN stated she had not checked the room earlier and that others might have moved it, even though the care plan required the call light to be within reach.
Surveyors found that a resident with ESRD on dialysis had two Velphoro phosphate binder tablets left in a cup at the bedside, contrary to facility policy requiring medications to be stored in locked compartments and administered under staff observation. The resident stated the tablets were his binders given that morning and that he chews those while staff watch him take other medications. Record review showed an active Velphoro order but no physician order or care plan authorization for self‑administration, and staff interviews (including an MA, RN, DON, and the Administrator) confirmed that no residents were approved to self‑administer medications and that medications should never be left at the bedside. This resulted in unsecured medication accessible to the resident outside of proper storage and administration procedures.
A resident with spine fractures, bladder CA, muscle weakness, and ADL self-care deficits, who required assistance with hygiene and toileting, reported feeling demoralized by the poor condition of his bathroom. Surveyors observed that the bathroom, containing a toilet, sink, and shower, had multiple stained, damaged areas and holes in the walls. The Administrator acknowledged that he and the Maintenance Director had discussed repairs to the room but had not started them, despite a facility policy stating residents’ rights to dignity and reasonable accommodation of their needs and preferences.
A resident with COPD, moderate cognitive impairment, and a documented mood disorder with risk of giving away possessions was involved in an incident where a housekeeper, despite prior training on a no-gratuities/no-loans policy, admitted using the resident’s money and debit card to purchase fast food for herself and the resident. The resident reported that the staff member went through his wallet and stole cash, denied authorizing her to use his debit card or money for food, but acknowledged buying small cigarettes from her with cash. The administrator confirmed the staff member’s admission that she used the resident’s funds for these purchases, constituting misappropriation of resident property.
A resident with severe dementia and depression, who was independent in self‑care and mobility and lived on a secure memory care unit, was transferred to another facility without a documented valid basis for discharge, without timely written notice to both resident representatives, and without adequate discharge planning. The record showed no evidence of a 30‑day written notice, no documentation that both POAs were involved in developing a discharge plan, and no post‑discharge plan of care. The DON completed a discharge summary listing the need for a larger locked unit as the reason for discharge, but the physician section was unsigned, and the transfer occurred rapidly after the LMSW discussed a possible move with one POA. Emails and interviews revealed that one POA believed she had only agreed to consider a move closer to her, the other POA explicitly stated she did not approve the transfer, and both were notified by email only after the resident had already been transferred. The facility’s own discharge/transfer policy requiring individualized discharge planning, advance written notice, and a post‑discharge plan of care was not followed or documented in this case.
Two residents received wound care in which an RN failed to follow infection control protocols, including inadequate hand hygiene, improper use of PPE, and placing contaminated items on clean surfaces. The DON confirmed these actions did not meet facility policy or professional standards, and facility policies and CDC guidelines emphasized the need for proper infection prevention practices.
Two residents with severe cognitive impairments did not have their privacy maintained during wound care, as an RN performed procedures without closing the door, privacy curtain, or blinds, despite facility policy and staff expectations requiring these privacy measures.
A deficiency was cited when an area of the facility was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
A resident with dementia and a history of wandering eloped from the secure unit and was not reported missing to authorities within the required 2-hour timeframe. Facility staff became aware of the absence hours after the resident left, and the administrator delayed notification until the resident was found and hospitalized for heat stroke. Leadership interviews revealed confusion about the correct reporting requirements.
Required daily nurse staffing and census information was not posted as mandated on one reviewed day. The DON and receptionist confirmed the absence of the posting, and the CNA responsible for scheduling did not provide a reason for the omission. The lapse was attributed to a transition in staff scheduler duties and lack of formal policy, with the ADMIN and DON acknowledging the regulatory requirement for daily posting.
A resident with severe cognitive impairment and mobility issues was able to leave the facility unsupervised through a side door with a disabled alarm. Staff were unaware of the resident's absence until notified by another resident, and the individual was found walking outside with a walker. The care plan did not address wandering or exit-seeking, and the elopement risk assessment did not identify the resident as at risk. The deficiency resulted from inadequate supervision and failure to maintain functional door alarms.
Multiple incidents of alleged abuse and resident-to-resident altercations were not reported to the administrator or State Survey Agency within the required timeframes. In several cases, staff delayed reporting for days or months, despite being trained on abuse and neglect policies. These delays were due to miscommunication, assumptions about the incidents' severity or credibility, and uncertainty about reporting responsibilities.
A resident with a history of behavioral issues physically abused two other residents during separate incidents, resulting in injuries. The facility failed to develop a care plan, monitor behaviors, or train staff to prevent further abuse, despite being aware of the resident's aggressive behavior. This inaction placed all residents at risk for harm.
The facility failed to develop comprehensive care plans for three residents with mental health issues, leading to unaddressed behaviors and incidents. A resident with schizophrenia and depression exhibited stealing and aggression, resulting in altercations with others. Another resident with schizoaffective disorder lacked interventions for his behaviors and altercations. A third resident with severe cognitive impairment had no care plan addressing his mental health needs. This deficiency highlights a systemic issue in addressing residents' mental health and behavior needs.
A resident with Parkinson's, acute kidney failure, schizophrenia, and dementia experienced significant changes in condition, including anxiety, panic, and tremors. The facility failed to notify the physician, leading to a delay in medical intervention. The resident was later hospitalized with sepsis and other conditions.
A resident with severe cognitive impairment and incontinence was not provided timely incontinent care, as required by their care plan. The resident was found with a wet brief and bed, and staffing issues were noted, with only one CNA available to assist at the time. Inconsistencies in care documentation and adherence to the care plan were identified, contributing to the deficiency.
A facility failed to document a resident's vital signs accurately in the EMR, despite the resident having significant medical conditions. The resident's vital signs were noted as stable or WNL without specific details, and an LVN did not document vital signs before initiating CPR. The DON confirmed that full documentation was expected, as per the facility's policy.
The facility failed to distribute mail received on Saturdays to residents, leading to delays in mail delivery. Residents expressed feeling disrespected by this practice. Interviews with staff confirmed that mail received on Saturdays was left unsorted until Monday, contrary to the facility's policy on mail delivery and distribution.
The facility failed to provide appropriate activities for three residents with varying levels of cognitive impairment. Despite care plans indicating the need for social, mental, and physical stimulation, the only documented activity was mail delivery, which was not considered an appropriate activity by the Activity Director. Comprehensive activity assessments and regular progress notes were also lacking.
The facility failed to ensure a resident's call light was within reach, despite the resident's impaired vision and need for assistance. The call light was found wrapped around the call light box on the wall, and the resident confirmed it was often moved away from him. The CNA admitted to forgetting to place it back within reach, and the DON acknowledged the expectation for call lights to be accessible.
A facility failed to transmit an accurate resident assessment for a discharged resident with Alzheimer's Disease, General Anxiety Disorder, and Hypertension. The discharge MDS was incorrectly marked as return anticipated, despite the resident being transferred to the hospital and not returning. Staff interviews revealed unawareness of the error, and the facility lacked a specific policy for MDS transmission.
The facility failed to ensure accurate PASRR Level 1 screening for a resident with mental illness, resulting in the resident's diagnosis of bipolar disorder and PTSD not being captured. This oversight was identified through record reviews and staff interviews, revealing that the resident required anti-psychotic medications and had a diagnosis of mental illness that was not reflected in the PASRR screening.
A resident with severe cognitive impairment, rheumatoid arthritis, depression, and diabetes mellitus was found with severely overgrown and neglected toenails. The facility failed to include the resident on the list for podiatric care, and there was no documentation of previous podiatric care or resistance to care.
A resident with severe cognitive impairment eloped from the facility twice by escaping through windows, despite being placed on 15-minute checks after the first incident. The facility's failure to adequately supervise and secure the environment led to Immediate Jeopardy as past non-compliance.
Failure to Obtain Signed Psychotropic Medication Consents and Inform Residents/Responsible Parties
Penalty
Summary
Surveyors found that the facility failed to ensure residents were fully informed of, and able to participate in, decisions about their psychotropic medications, and failed to obtain required signed consents for these drugs. For one resident with Parkinson’s disease, COPD, dementia, psychotic disorder with delusions, schizoaffective disorder, and major depressive disorder, records showed care plan problems including verbal abuse, fall risk, inappropriate sexual comments, and use of antipsychotic and antidepressant medications. Physician orders included Ativan for agitation, Oxcarbazepine for psychotic disorder with delusions, and Nuplazid for psychosis, all without stop dates. The resident was her own responsible party and had a BIMS score of 5 indicating severe cognitive deficit, but there were no signed consents in the EHR for two antipsychotic medications. The DON stated that signed consents were not needed for Ativan used for anti-anxiety and that an EHR-generated consent was sufficient, despite the EHR consent form instructions requiring a printed copy signed by the resident or responsible party for each psychoactive medication. For another resident with dementia, depression, and anxiety disorder, care plans identified falls, aggression, and elopement risk, and the admission MDS showed a BIMS score of 3 indicating severe cognitive deficit, with anxiety and antipsychotic medication coded. Physician orders included scheduled and PRN Ativan for anxiety with specified start and stop dates. During observation, this resident appeared drowsy, was nodding, and had slurred speech while in a secured unit dining room. The resident’s responsible party reported that the medication helped calm the resident’s behavior and expressed hope that the drowsiness would lessen over time. When the DON reviewed the EHR with the surveyor, there were no copies of signed consents for this resident’s antipsychotic medication. Facility policy defined psychotropic drugs to include antipsychotic, antidepressant, antianxiety, and hypnotic medications, and the EHR psychotropic consent form instructions required review of reason, expected benefits, side effects, and course of treatment with the resident or responsible party, and a printed, signed consent for each medication, which had not been obtained for these residents.
Improper Storage of Nebulizer Mask and Tubing for COPD Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care by not properly storing nebulizer equipment for a resident who required respiratory treatments. The resident was an older male with COPD, emphysema, hemiplegia and hemiparesis following a stroke, and essential hypertension, with intact cognition per a recent MDS. Physician orders included PRN oxygen at 2 LPM via nasal cannula for shortness of breath and PRN albuterol nebulizer treatments every six hours for cough and congestion. The resident’s comprehensive care plan addressed his COPD/emphysema and shortness of breath, including interventions for oxygen therapy and monitoring for respiratory infection and respiratory insufficiency. During observation, the resident was seen seated in a wheelchair in his room, where an unprotected nebulizer face mask and tubing were lying on the bedside table attached to a nebulizer machine on top of a personal refrigerator, with no receptacle available in the room for storing the equipment. The resident identified the mask as being for his COPD treatment. Multiple staff, including an LVN, MA, RN, and the DON, stated that respiratory equipment such as oxygen tubing, nasal cannulas, and masks should be placed in plastic bags when not in use to prevent contamination, and that if not bagged, they should be switched out. The LVN reported the tubing and mask were new and had been replaced that morning after a deep cleaning, and staff had not yet bagged them. Review of the facility’s oxygen administration policy showed it addressed changing tubing when malfunctioning or visibly contaminated but did not address storage of respiratory tubing or masks, and the DON could not provide a policy specific to storing respiratory equipment.
Unsupervised Resident Elopement Through Keypad-Controlled Exit
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents, resulting in a resident leaving the facility without staff knowledge. The resident was an older female with multiple diagnoses including cerebral infarction, COPD, abnormal posture, muscle weakness, lack of coordination, dementia with agitation, heart failure, asthma, and a right wrist fracture. Her most recent MDS indicated adequate vision, cognitive intactness for daily decision-making, and independence with mobility, while her care plan documented impaired cognitive function, forgetfulness, and dementia with agitation. An elopement risk assessment documented that she ambulated independently, understood and accepted the need for nursing home care, had reasonable decision-making skills, no prior attempts to leave, recognized traffic controls, and knew her current residence. On the evening of the incident, the resident received medications from an LVN at approximately 9:40 p.m. and expressed grievance about having a roommate after being promised a private room. The LVN reported calling the Administrator in the resident’s presence to relay the grievance, and the resident appeared satisfied at that time. Another resident in the same room stated that both received medications at around 8:30 p.m., that the aggrieved resident left the room around that time, and that she was not in the room when the roommate went to sleep at about 10:30 p.m. The roommate also reported that typically no one checked on her after the last medication pass and that she left her door slightly open if she needed staff attention. Video footage showed the resident on the B Hall unit with two CNAs in the shower room between 11:00 p.m. and 11:15 p.m., then exiting the shower room around 11:30 p.m. with a CNA and walking with a walker back toward her room. At approximately 11:35 p.m., the resident was seen at the front door, using the keypad to activate the door code and exiting onto the sidewalk without staff intervention. The Administrator later stated that the resident had previously gone to a local fast-food restaurant but only when accompanied by staff, and that she somehow obtained or deduced the front door code despite not being given it. EMS contacted the facility close to midnight to verify whether the resident lived there, and the LVN subsequently found her at a nearby fast-food restaurant, where she appeared confused and denied recognizing him. The facility’s own policy on resident rights and safe environment stated that residents have the right to a safe environment and to receive care and services safely, but the resident was able to leave the building unsupervised by manipulating the keypad and walking approximately 0.1 miles away before staff became aware.
Improper Storage of Insulin Pen on Medication Cart
Penalty
Summary
The deficiency involved the facility’s failure to properly secure and store a resident’s insulin Lispro pen in a locked medication cart as required by facility policy and professional standards. Surveyors observed three medication carts on the 300 Hall, with the middle cart having an insulin Lispro pen sitting on top of the cart counter, labeled with Resident #2’s name, rather than being locked inside the cart. Record review showed that this resident was a cognitively intact male with type 1 diabetes and dependence on renal dialysis, with active orders for insulin Lispro via pen-injector for use before dialysis sessions and per sliding scale with meals. During interview, LVN E reported that she had obtained and administered a dose of insulin Lispro to this resident earlier in the day and had written the open date on the insulin cap. She stated she believed the insulin pen may have been left on top of the cart by the previous shift because the counter area where it was found was not her assigned cart, and she could not recall whether she had failed to lock the insulin pen in her own cart. LVN E acknowledged that all medications should always be locked in the medication cart. The DON confirmed that medications, including insulin, were required to be locked in the medication cart immediately after use, that only nursing staff were allowed to administer insulin, and that an unlocked insulin pen was considered a safety concern. Facility policy on Medication Storage in the Facility stated that medications and biologicals must be stored safely, securely, and properly, and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications.
Incomplete Documentation of Daily Wound Treatment on TAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident receiving a prescribed wound treatment. A male resident with diabetes, muscle weakness, lack of coordination, urinary retention, and pain was identified as cognitively intact and at risk for pressure ulcer/injury. His physician’s order and MAR directed that TRIAD be applied to his buttocks once daily for wound healing, with no end date. However, review of the Treatment Administration Record (TAR) showed missing documentation for this TRIAD treatment on multiple dates (3/1/25, 3/6/26, 3/7/26, 3/11/26, 3/13/26, 3/14/26, 3/15/26, and 3/16/26). The resident’s care plan documented risk for altered skin integrity related to impaired mobility, with interventions to reduce friction, but the corresponding daily treatment documentation was incomplete. During interviews, the resident reported he had complained about staff not administering some medications, acknowledged he often refused medications, but stated he had been receiving a cream treatment to his buttocks every morning and did not want the area to worsen. The ADON confirmed the expectation that staff document all medications and treatments on the MAR/TAR, including refusals, and stated there should be no blanks because they could be interpreted as missed medications or treatments. The ADON and DON both stated that in this resident’s case, he frequently refused medications but did not refuse the TRIAD treatment. Nursing staff, including an LVN, stated that floor nurses were responsible for wound care treatments and that any treatment not done as ordered, or refused, should be documented at the time, with no blank spaces on the MAR/TAR. Facility policy on documentation required complete, accurate, timely, and properly signed clinical record entries, including on medication sheets, but the missing TAR entries for the TRIAD treatment showed this standard was not met for the resident.
Call Lights Not Kept Within Reach of Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that call lights were accessible to residents who required a means to request assistance, as required by their care plans and facility expectations. For one resident with dementia, impaired cognition, and osteoarthritis, the care plan included interventions to provide a safe environment by keeping the call light within reach and encouraging its use for assistance. During an observation, this resident was found lying in bed with the call light wrapped and hooked onto the wall behind the headboard, away from the door and out of her reach. When asked, the resident attempted to reach over her shoulder but could not touch the call light and did not know how long it had been in that position. A medication aide stated that the resident used her call light, that it was supposed to be within reach and clipped to the bed, and that staff were expected to check call lights during two-hour rounds and while passing medications. The aide acknowledged having seen the call light hooked on the wall earlier that morning and had not yet repositioned it because she was providing care to another resident. Another resident with a neurocognitive disorder with Lewy bodies, lack of coordination, and anxiety disorder had a care plan that directed staff to encourage the resident to use the bell to call for assistance and to have an agreed-on method, such as a call light or bell, to relieve anxiety. This resident was observed asleep in bed with the call light lying under the bed against the wall, out of reach. The resident could not be roused sufficiently to follow directions or demonstrate whether she could reach the call light. Two CNAs later stated that this resident did not use her call light but acknowledged that, despite this, the call light was supposed to be within the resident’s reach. One CNA picked up the call light from the floor and clipped it to the bed, confirming that it had been out of reach at the time of the observation. A third resident with cerebral palsy, severe intellectual disabilities, lack of coordination, and non-verbal communication had a care plan intervention to ensure a safe environment by keeping the call light within reach. During an observation, this resident was initially asleep and later awake but non-verbal. The call light in this room was found wrapped and hooked onto the wall toward the center of the room, past the footboard, and out of the resident’s reach. An LPN stated she did not know why the call light was hooked on the wall and that she had not had a chance to check the room earlier that morning. She reported that the resident normally did not or could not use the call light, but that it was usually clipped to the bed, and that housekeeping, night shift, or others could have placed it on the wall. The DON and the administrator both stated that their expectation was for call lights to be within reach of residents and acknowledged that call lights out of reach could result in residents’ needs not being addressed in a timely manner. The facility’s fall policy also specified that call bells should be positioned within reach as part of environmental fall prevention measures.
Unsecured Phosphate Binder Tablets Left at Bedside Without Self‑Administration Authorization
Penalty
Summary
Surveyors identified a deficiency in medication storage and control when two orangish-brown, disk-like Velphoro (sucroferric oxyhydroxide) tablets were observed in a disposable plastic cup on Resident #4's bedside table. Resident #4, a male with end stage renal disease and dependence on renal dialysis, stated he had just returned from dialysis and that the pills were his phosphate binders given to him that morning. He reported that he chews those binders and that staff watch him take his other medications. At the time of the observation, the Velphoro tablets were not secured in a locked compartment, and there was no documentation that he was authorized to self-administer medications. Record review showed an active order for Velphoro 500 mg chewable tablets, two tablets by mouth with meals for end stage renal disease, with no order permitting self-medication. A Self Medication Program Assessment dated earlier indicated the resident was fully capable in understanding and managing medications, but the care plan documented impaired cognitive function/dementia with a BIMS score of 8.0 and included no focus or intervention for self-medication. The quarterly MDS, however, reflected a BIMS score of 15.0, indicating cognitive intactness, creating inconsistency between assessments and the care plan regarding his cognitive status and self-medication capability. Interviews with staff further clarified that facility practice and policy required medications to be administered by authorized personnel and that staff were to observe residents taking medications, with no medications to be left at the bedside. The MA interviewed stated she had not yet administered the resident’s medications that morning and that staff were supposed to watch residents take their medications. The RN stated phosphate binders were supposed to be watched by staff when administered and swallowed. The DON and Administrator both confirmed that residents were only allowed to self-administer medications following an assessment, physician authorization, and care plan documentation, and that, to their knowledge, no residents were currently permitted to self-administer. Despite these policies, Resident #4 had Velphoro tablets left at his bedside, accessible and not under staff observation, constituting the cited deficiency in secure medication storage and control of access to medications.
Failure to Maintain Clean and Well-Maintained Resident Bathroom Environment
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a sanitary, orderly, and comfortable interior environment for a resident. The resident was an older male admitted for LTC with diagnoses including mid-back spine fractures at T7–T8 and T11–T12, bladder cancer, and muscle weakness, and he required assistance with hygiene and toileting per his MDS and care plan. His care plan documented an ADL self-care performance deficit, a need for staff assistance with bathing, and that discharge from the facility was not feasible due to his inability to care for himself independently. During an interview and observation, the resident was found in his room and reported feeling demoralized by his poorly maintained bathroom. Observation of the bathroom revealed a toilet, sink, and shower, with the bathroom walls noted to be stained in 5 to 10 areas, damaged, and with holes. In a subsequent interview, the Administrator stated that he and the Maintenance Director had discussed repairs to the resident’s room but that the repairs had not yet begun. The facility’s Residents Rights policy stated that residents have the right to a dignified existence, respect and dignity, and to reside and receive services with reasonable accommodation of their needs and preferences, which contrasted with the observed condition of the resident’s bathroom.
Misappropriation of Resident Funds by Housekeeping Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property and to uphold its own policy prohibiting staff from accepting gratuities, gifts, or loans from residents. The facility’s undated Freedom from Abuse Notice and related policy clearly state that staff are not to accept any form of currency, items of monetary value, or services from residents or their representatives. Despite having received and signed training on this policy on 8/24/2025, a housekeeper (HK F) acknowledged taking a resident’s debit card and using the resident’s money to purchase fast food for herself and the resident. The resident, a male admitted for LTC with COPD and ADL support needs, had a BIMS score of 12 indicating moderate cognitive impairment, adequate hearing, impaired vision with glasses, and was usually able to understand and make himself understood. The resident’s care plan documented a mood problem related to depression and noted a risk for harm to self, including risky actions such as giving away possessions. During interviews, HK F stated that since meeting the resident in August 2025, he had asked her to buy fast food for both of them, and she admitted using his money for these purchases. The resident, however, reported being upset with HK F, stating she stole $40 in cash and went through his wallet, and denied giving her his debit card or money to buy food, though he acknowledged purchasing small cigarettes from her with cash. The resident showed his wallet containing a debit card and about $50 in cash and reported that HK F had stolen $40. The administrator confirmed that HK F admitted using the resident’s money to purchase food for herself and the resident, and that this conduct violated the facility’s policy on misappropriation of resident property.
Failure to Document Basis, Notification, and Planning for Resident Transfer/Discharge
Penalty
Summary
The deficiency involves the facility’s failure to properly document and justify a facility-initiated transfer/discharge, to adequately notify and involve the resident’s representatives, and to complete required discharge planning and summaries for a resident with severe dementia. The resident was an elderly female with unspecified dementia with agitation, unspecified dementia with behavioral disturbance, and major depressive disorder. Her annual MDS showed a BIMS score of 06, indicating severely impaired cognition, and documented non‑Alzheimer’s dementia and depression treated with antidepressants. Despite her cognitive impairment, she was independent in self‑care and mobility, and the MDS and a recent QRR summary indicated no verbal or physical behaviors directed toward others in the prior week. Her care plan documented dementia, safety/security issues, and placement in a secure memory care unit, and later revisions noted a history of aggression related to roommate situations and prior resident‑to‑resident altercations, but also that she did not currently have a roommate. Social service documentation showed that the LMSW contacted one family member (identified as a resident representative and POA) about “solutions” for a recent incident with another resident and that this family member stated she would be okay with a facility closer to her if it came to that alternative to give the resident more room to move around. However, the clinical record from admission forward contained no documentation of a valid regulatory basis for discharge. The discharge summary completed by the DON listed the reason for discharge as requiring a locked unit that allows more space to move around and indicated discharge to another staffed facility, but the physician signature and date lines were not completed. There was no evidence in the record of a written notice of transfer/discharge with reasons for the move, no 30‑day notice, and no documentation that the POA(s) were notified in advance of the actual transfer. The LMSW later sent an email to one POA after the transfer had already occurred, providing the name, address, and contact information of the receiving facility and describing it as a larger locked facility with more space and activities. Email correspondence between the LMSW and both POAs after the transfer reflected disagreement about whether consent for the move had been given. One POA wrote that she had only agreed to consider a move closer to her, denied agreeing to the suggested facility, and stated that incidents were not discussed at the time. The LMSW responded that he interpreted her statement (“if we have to move her then I guess we have to”) as agreement to transfer if needed. The second POA stated in a phone interview that she did not know why the resident was transferred, believed prior incidents had been handled and the resident was stable, and reported that the decision to move seemed abrupt. She stated she was contacted by the new facility’s admissions coordinator about transfer arrangements before she was aware of any approved transfer and that she told both the admissions coordinator and the LMSW she did not approve the move, yet the resident was transferred the next day. The nursing progress note documented that the resident left the facility via wheelchair with clothing and medications given to transport personnel, but the record contained no documentation of sufficient preparation and orientation of the resident for a safe and orderly transfer, no evidence of an effective discharge planning process involving the resident and both resident representatives, and no discharge summary that included a post‑discharge plan of care developed with the participation of the resident representative(s), as required by facility policy and regulation. In interviews, the LMSW stated he was responsible for the transfer/discharge process, which should include discussing the transfer with the resident or POA, obtaining agreement, providing written notice, and, if there was disagreement, issuing a 30‑day discharge notice with appeal and Ombudsman information. He acknowledged that he notified one POA on a specific date that the resident would benefit from more space and that he believed she initially agreed to locating another facility. He also acknowledged that the transfer occurred very quickly, that his email notification to the POAs and Ombudsman went out after the resident had already been transferred, and that this was not the facility’s usual practice. He stated he was under pressure to get the resident transferred and that the DON’s relationship with the receiving facility expedited the process. The administrator stated the facility followed its discharge/transfer policy, but record review showed no documented basis for discharge, no documented prior notification to the POAs, no documented discharge planning process involving the resident and representatives, and no post‑discharge plan of care, contrary to the written policy that required individualized discharge planning, written notice for facility‑initiated non‑emergent transfers, and a post‑discharge plan of care. The facility’s own policy on Discharge or Transfer required that the discharge planning process address each resident’s discharge goals and needs, involve the resident and resident representative and the interdisciplinary team, and that for facility‑initiated non‑emergent transfers or discharges, the facility provide written notice to the resident and representative(s) with reasons for the move at least 30 days in advance, and send a copy to the State LTC Ombudsman. The policy also required a post‑discharge plan of care detailing arrangements made to address the resident’s needs after discharge and instructions given to the resident and representative. Review of the resident’s clinical record from admission onward showed no documentation that these policy requirements were met: there was no valid basis for discharge documented, no evidence of timely written notification to the POAs, no documentation of sufficient preparation and orientation for the resident, no evidence of an implemented and effective discharge planning process involving the resident and both resident representatives, and no discharge summary including a post‑discharge plan of care.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices during wound care for two residents. During wound care for a resident with a right femur fracture, Alzheimer's disease, and dementia, RN A placed wound care supplies on an unsanitized bedside table, donned a gown that came into contact with another resident and her bed, and failed to perform hand hygiene before donning gloves. RN A also touched the resident's wound with gloved hands without changing gloves or performing hand hygiene, and after cleaning the wound, donned new gloves without hand hygiene. The trash bag used for wound care was placed on the floor and later on top of the treatment cart without sanitization. RN A acknowledged these lapses during interviews, stating that proper hand hygiene and PPE removal were not followed. For another resident with a history of cerebral infarction, major depressive disorder, generalized anxiety disorder, and aphasia, RN A washed her hands for only four seconds before removing the resident's boot and did not perform hand hygiene before donning gloves. Wound care supplies were placed on an unsanitized bedside table, and the resident's foot was repeatedly set on a trash bag containing dirty dressings and cleaning liquid. RN A failed to perform hand hygiene after removing gloves and before donning new ones, and PPE was not removed before exiting the resident's room. The used gown was placed on top of the treatment cart before disposal. RN A admitted to not following expected hand hygiene and PPE protocols during interviews. The Director of Nursing (DON) confirmed that the observed practices did not align with facility policy or professional standards, noting that contaminated items such as trash bags and gowns should not be placed on clean surfaces or treatment carts. The DON also stated that bedside tables should be sanitized before and after use, and that hand hygiene should be performed at key points during wound care. Facility policies and CDC guidelines reviewed by surveyors supported these expectations, emphasizing the importance of hand hygiene, proper PPE use, and environmental cleaning to prevent cross-contamination.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to respect the personal privacy and dignity of two residents during wound care procedures. In both cases, the residents had significant cognitive impairments, as documented in their medical records and MDS assessments. For one resident with a right femur fracture, Alzheimer's disease, and dementia, wound care was performed on the right second toe without closing the door, privacy curtain, or blinds, while the resident's roommate was present in the room. The resident was unable to respond to questions during an interview, and later stated she did not have any wounds. For the second resident, who had a history of cerebral infarction, major depressive disorder, generalized anxiety disorder, and aphasia, wound care was performed on the left heel without closing the door or privacy curtain. This resident also had severely impaired cognitive skills and did not respond to questions about wound care. Interviews with the RN who performed the wound care and the DON confirmed that the facility's expectation was to always provide privacy by closing the door, privacy curtain, and blinds before providing care. The facility's policy and wound care checklist also required upholding dignity and privacy during care. Despite these policies and expectations, the required privacy measures were not followed during the observed wound care procedures for both residents.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Timely Report Resident Elopement and Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident's elopement within the required 2-hour timeframe to the State Survey Agency and other appropriate authorities. The resident, an elderly female with multiple diagnoses including multiple sclerosis, type 2 diabetes mellitus, and unspecified dementia, had a documented risk for elopement and wandering behavior. Despite interventions in her care plan for close supervision and increased monitoring, the resident was able to leave the secure unit undetected. Staff first became aware of her absence over two hours after she left, and a facility-wide search was initiated later that morning. The incident report shows that the administrator notified the Complaint and Incident Intake Department of the elopement by email approximately 14 hours after the resident was discovered missing, well beyond the required 2-hour reporting window. Interviews revealed confusion among facility leadership regarding the correct reporting timeframe, with the administrator believing notification could wait until the resident was found safe, and the compliance nurse incorrectly stating the requirement was 24 hours. The resident was ultimately found by family members in a car one block from the facility and was hospitalized for heat stroke related to the elopement.
Failure to Post Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to post required daily nurse staffing and census information on one of three days reviewed. On the specified date, observations between 2:24 p.m. and 2:47 p.m. confirmed that the information regarding current nurse staffing and census was not publicly posted. The Director of Nursing (DON) was unable to locate the posting and, upon inquiry, was informed by the receptionist that the information had not been posted that day. Interviews revealed that the Certified Nurse Aide (CNA) responsible for staff scheduling did not provide a reason for not posting the schedule and census. The DON stated that the staff scheduler was responsible for printing and posting the daily schedule and census, but on the day in question, the scheduler appeared unaware that this was part of their duties, despite having completed the task during recent relicensing certification observations. Further interviews indicated that the facility did not have a formal policy on posting the daily census and nurse staffing, but staff were aware that regulations required this information to be posted daily. The Administrator (ADMIN) confirmed that the staffing coordinator was responsible for posting the information, with Assistant Directors of Nursing (ADONs) as backups. The ADMIN was not aware of the missed posting until after the fact and attributed the lapse to a transition in staff scheduler responsibilities and incomplete training of the new staff member. No residents or facility guests had requested to view the posting on the day it was missing.
Failure to Prevent Resident Elopement Due to Disabled Door Alarm and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including schizoaffective disorder and muscle weakness, was able to leave the facility unsupervised. The resident exited through a side door whose alarm had been turned off, and staff were unaware of her absence until notified by another resident who was outside. The resident was found walking with her walker on the sidewalk approximately 400 feet from the facility, heading toward a nearby restaurant. At the time of the incident, the resident's care plan did not include interventions for wandering or exit-seeking, and her most recent elopement risk assessment indicated she was not at risk for elopement. The facility's failure to provide adequate supervision and maintain functional door alarms directly contributed to the resident's elopement. The double doors by the dining room, which the resident used to exit, were found to have their alarm system turned off. Maintenance staff later confirmed that the alarm could be disabled with a key, and that multiple staff members had access to these keys. The facility's policy required the use of door alarms or monitoring devices to notify staff when residents attempt to leave, but this was not followed in this instance. Interviews with staff and review of records confirmed that the resident was not identified as an elopement risk prior to the incident, and there were no care plan interventions addressing wandering or exit-seeking behaviors. The lack of appropriate risk assessment, supervision, and environmental safeguards led to the resident leaving the facility without staff knowledge, resulting in a deficiency related to accident prevention and resident safety.
Failure to Timely Report Alleged Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the administrator and to the State Survey Agency, as required by regulation. Multiple incidents involving both resident-to-resident and resident-to-staff allegations of abuse were not reported within the required timeframes. In several cases, incidents were reported days or even months after they occurred, despite staff being trained on the abuse and neglect policy and procedure. One incident involved a resident with severe dementia and agitation physically attacking another resident, resulting in scratches and hair pulling. Although staff intervened and separated the residents, the incident was not reported to the State Survey Agency until two days later. In another case, a resident pushed another resident, causing a fall, but the event was not reported for over two months. Staff interviews revealed confusion about reporting requirements, with some staff believing the incident was not reportable due to the cognitive status of the residents or lack of injury, despite facility policy mandating immediate reporting of all suspected abuse. Additional incidents included a resident accusing staff of abuse, which was not reported until two days after the allegation, and a physical altercation between two residents that was not reported to the administrator or State Survey Agency until three days after the event. Documentation and interviews confirmed that staff were aware of the incidents but failed to report them in a timely manner. The delays in reporting were attributed to miscommunication, assumptions about the severity or credibility of the allegations, and lack of clarity regarding who was responsible for making the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and misappropriation of property, specifically involving two residents who were victims of physical abuse by another resident. Resident #2 was physically abused by Resident #1 during a smoke break, where Resident #1 grabbed, scratched, and hit Resident #2 after an altercation over a purse. Despite the incident, the facility did not develop a care plan, monitor behaviors, or train staff to prevent further abuse. Resident #1 had a history of behavioral issues, including stealing from other residents, but these behaviors were not addressed in his care plan. Resident #3 was also a victim of physical and psychological abuse by Resident #1, who repeatedly hit Resident #3 in the face and head, causing visible injuries. This incident occurred after a verbal altercation between the two residents, and despite being informed of Resident #1's aggressive behavior, the facility failed to implement effective interventions or behavior management strategies. Resident #1 was eventually arrested and charged with a felony for the abuse of Resident #3. The facility's inaction and lack of appropriate interventions placed all residents at risk for abuse and harm. Staff interviews revealed a lack of training on handling resident behaviors and aggression, and there was no evidence of behavior monitoring for Resident #1. The facility's failure to address known behavioral issues and protect residents from abuse resulted in significant deficiencies in resident care and safety.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which led to a deficiency in meeting their medical, nursing, and psychosocial needs. Resident #1, who had a history of mental illness including schizophrenia and depression, exhibited behaviors such as stealing and aggression. Despite these behaviors being documented in progress notes and incidents, the care plan did not address behavior management or interventions to prevent altercations with other residents. This oversight resulted in multiple incidents, including physical altercations with other residents during smoke breaks. Resident #2, diagnosed with schizoaffective disorder and other mental health issues, also lacked a comprehensive care plan addressing his mental health needs and behaviors. His care plan did not include interventions for his altercation with Resident #1 or strategies to manage his refusal of medications and anxiety around smoke breaks. The absence of a detailed care plan left Resident #2 without proper guidance for staff to manage his behaviors and prevent future incidents. Resident #3, with severe cognitive impairment and a history of schizoaffective disorder, did not have a care plan addressing his mental health diagnosis or behaviors. His care plan failed to include interventions following an altercation with Resident #1, which could have provided necessary support for potential PTSD. The facility's lack of comprehensive care plans for these residents highlights a systemic issue in addressing and documenting mental health needs and behaviors, leading to potential harm and unmet resident needs.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's condition, which is a requirement when there is a deterioration in health, mental, or psychosocial status. This deficiency was identified for one resident who experienced a change in condition but whose physician was not informed in a timely manner. The resident, who had a history of Parkinson's disease, acute kidney failure, schizophrenia, and dementia, showed symptoms of anxiety, panic, dizziness, fear, and tremors over several days. Despite these symptoms, there was no documentation that the physician or nurse practitioner was notified of the resident's condition change on the specified date. Interviews with staff revealed that the resident exhibited neurological changes, excessive shaking, and trembling, and required more assistance with activities of daily living. The resident was eventually sent to the hospital, where they were diagnosed with sepsis, acute encephalopathy, dehydration, and acute kidney injury. The failure to notify the physician was confirmed through interviews with the medical director and nursing staff, who stated they were not informed of the resident's condition change. The facility's policy required immediate notification of the physician with significant changes in status, but this was not adhered to, leading to a delay in medical intervention for the resident.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to a resident who was unable to perform activities of daily living independently. The resident, who had severe cognitive impairment and was always incontinent of bowel and bladder, was found with a wet brief and bed on a specific date. The resident's care plan required incontinent care at least every two hours, but there was no documentation indicating that the resident refused care, and the care task record showed the last toilet use was recorded several hours before the incident. On the day of the incident, the resident's daughter reported finding her mother in a wet state, with the call light on, and only one CNA available to assist. The Director of Nursing (DON) confirmed the resident was wet and being changed by the Charge Nurse. Staffing records indicated there were two CNAs scheduled for 33 residents, but one CNA was not assigned to the resident. Interviews with staff revealed inconsistencies in care documentation and expectations, with CNAs not consistently documenting when residents were checked or changed. The facility's policy required residents using absorbent products to be checked and changed based on a schedule aligned with professional standards and the resident's voiding pattern. However, the DON acknowledged that the resident was not checked as frequently as expected, which was not acceptable. The lack of consistent documentation and adherence to the care plan contributed to the deficiency in providing necessary care and services to the resident.
Failure to Document Vital Signs Accurately
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of vital signs. The resident, who had a history of Parkinson's Disease, acute kidney failure, schizophrenia, and dementia, was admitted to the facility and had a BIMS score indicating severe impairment. On two occasions, the resident's vital signs were not documented in the electronic medical record (EMR), which is a requirement according to professional standards and the facility's policy. This lack of documentation was noted during a review of the resident's progress notes, where vital signs were mentioned as stable or within normal limits (WNL) without specific details. Interviews with facility staff revealed a misunderstanding or neglect of documentation protocols. An LVN involved in the resident's care admitted to not documenting vital signs before initiating CPR, assuming it was implied by the action taken. The Director of Nursing (DON) confirmed that a full set of vital signs should have been documented whenever they were taken. The facility's policy on cardiopulmonary resuscitation also emphasized the need to document all care given and the resident's response to treatment, highlighting the deficiency in maintaining accurate medical records.
Failure to Distribute Resident Mail on Saturdays
Penalty
Summary
The facility failed to promote the residents' right to receive mail in a timely manner. Specifically, facility staff did not distribute mail received on Saturdays to the residents. During a confidential group meeting, residents expressed that they do not receive mail on Saturdays and felt this practice was disrespectful. Interviews with the Assistant Director (AD), Assistant Business Office Manager (ABOM), and Weekend Receptionist confirmed that mail received on Saturdays was left unsorted until Monday. The Director of Nursing (DON) acknowledged that residents should receive their mail on Saturdays. A review of the facility's undated policy on Resident Mail Delivery and Distribution revealed that the facility is required to develop a system to deliver and distribute resident mail in accordance with privacy and confidentiality regulations.
Failure to Provide Appropriate Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, as evidenced by deficiencies found for three residents. Resident #14, who has severe cognitive impairment due to Neurocognitive Disorder with Lewy Bodies, Depression, and Anxiety Disorder, was not provided with activities designed to meet her interests and promote her well-being. Despite her care plan indicating the need for social, spiritual, and mental stimulation activities, the only documented activity was mail delivery, during which she was asleep, and the mail was left at her bedside without further engagement from the staff. Resident #48, a male with severe cognitive impairment, Dementia, cognitive communication deficit, epilepsy, and psychosis, also did not receive appropriate activities. His care plan indicated a preference for independent activities and occasional group activities. However, there were no activity assessments completed since his admission, and the only documented activity was mail delivery, which was not considered an appropriate activity by the Activity Director. Observations showed him sitting in the common area without engaging in meaningful activities. Resident #73, with mild cognitive impairment, Chronic Kidney Disease, and Cognitive Communication Deficit, was similarly affected. Her care plan noted her limited interest in activities but enjoyment of bingo, crosswords, and coloring. The only documented activity was mail delivery, which she chose to open later. The Activity Director acknowledged that mail delivery should not be counted as an activity and stated the need for re-education of the staff. The facility's policy required comprehensive activity assessments and regular progress notes, which were not adhered to in these cases.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a reasonable accommodation of resident needs and preferences. Specifically, Resident #21, a male with end-stage renal disease, PTSD, and Type II diabetes, was observed to have his call light wrapped around the call light box on the wall, making it inaccessible. This observation was made on 5/28/24 at 10:45 a.m. Resident #21, who has intact cognition and impaired vision, confirmed in an interview that the call light was often moved away from him, preventing him from calling for assistance. CNA D, the assigned nursing assistant for Resident #21, admitted to forgetting to place the call light within the resident's reach after providing incontinent care that morning. The Director of Nursing (DON) stated that it is the facility's expectation that call lights should be within arm's length of all residents and acknowledged that the lack of accessibility could lead to falls or other issues. The DON also mentioned that charge nurses are responsible for ensuring call lights are within reach during daily administration rounding, although no specific policy addressing call lights was provided.
Failure to Transmit Accurate Resident Assessment
Penalty
Summary
The facility failed to transmit the resident assessment within the required time frame for a discharged resident. Specifically, the facility did not submit a discharge not anticipated MDS for a resident who was transferred to the hospital and did not return to the facility. The resident, a male with Alzheimer's Disease, General Anxiety Disorder, and Hypertension, was admitted to the facility and later discharged. The discharge MDS was incorrectly marked as return anticipated, despite the resident being transferred to the hospital and not returning within 30 days. Interviews with the MDS Nurse, DON, and Administrator revealed that they were unaware of the error in marking the discharge MDS as return anticipated. The facility did not provide a policy for transmitting MDS, relying instead on the RAI manual. The CMS's RAI Version 3.0 Manual specifies that if a resident will not return to the facility, the discharge should be marked as return not anticipated. This oversight could lead to inaccuracies in resident assessments and data transmission.
Failure to Ensure Accurate PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment. Specifically, Resident #21's PASRR Level 1 assessment did not accurately capture the resident's diagnosis of mental illness. The resident, a [AGE] year-old male admitted with diagnoses including end-stage renal disease, post-traumatic stress disorder (PTSD), and diabetes type II, had a PASRR Level 1 screening that incorrectly indicated no evidence of mental illness. This oversight was identified during a review of the resident's face sheet, admission MDS, and care plan, which revealed the resident required anti-psychotic medications and had a diagnosis of bipolar disorder and PTSD. During interviews, the MDS Coordinator acknowledged the error and stated that the PASRR 1 screening should have been redone as positive. The Director of Nursing (DON) also confirmed that it was expected for the MDS Coordinator to review all residents' medication orders to ensure no PASRR positive resident was missed. The facility's policy on PASRR maintenance indicated that all confirmed positive or negative PASRR evaluations should be obtained from the local health authority, which was not followed in this case.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to ensure proper foot care for a resident, leading to discomfort and potential health risks. The resident, an elderly female with severe cognitive impairment, rheumatoid arthritis, depression, and diabetes mellitus, was observed with severely overgrown, thick, curved, ragged, chipped, uneven, cracked, and yellowish toenails. The toenails were causing reddened areas around the nail bed and were not properly trimmed or maintained. Despite the resident's eligibility for podiatric care, she was not included on the list for the podiatrist's visit, and there was no documentation indicating she had ever received care from a podiatrist or resisted care from the staff. Interviews with the ADON and social worker revealed that the facility's process for scheduling podiatric care was flawed. The social worker, responsible for compiling the list of residents needing podiatric care, failed to include the resident on the list. Additionally, the facility was unaware of the podiatrist's visit on the day of observation, further complicating the resident's access to necessary care. The DON confirmed the lack of documentation and noted that the resident's toenails were still long even after staff intervention. The facility's policy emphasized the importance of foot care, especially for residents with diabetes, but the policy was not effectively implemented in this case.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents. Resident #1, who had severe cognitive impairment and was admitted to the secured unit, eloped from the facility twice. The first elopement occurred on 02/21/2024 when the resident escaped through his bedroom window by removing the glass windowpane. The second elopement happened on 03/04/2024 when the resident broke a window in another resident's room and was found at a bus stop down the street from the facility. Despite being placed on 15-minute checks after the first elopement, the facility failed to prevent the second elopement. Interviews with staff revealed that Resident #1 was difficult to care for and often threatened staff when redirected from attempting to elope. The facility's elopement response policy was enacted during both incidents, but the measures taken were insufficient to prevent the resident from eloping again. The facility's documentation showed that the resident was eventually placed on 1:1 observation while in his room and visual checks every 15 minutes when not in his room. However, these measures were implemented only after the second elopement. The facility's failure to adequately supervise and secure the environment for Resident #1 led to the identification of Immediate Jeopardy as past non-compliance, which began on 02/21/2024 and ended on 03/05/2024.
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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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