Paradigm At The Prairies
Inspection history, citations, penalties and survey trends for this long-term care facility in El Campo, Texas.
- Location
- 106 Del Norte Dr, El Campo, Texas 77437
- CMS Provider Number
- 676040
- Inspections on file
- 40
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 15 (2 serious)
Citation history
Health deficiencies cited at Paradigm At The Prairies during CMS and state inspections, most recent first.
The facility failed to honor resident rights to self-determination by not allowing residents and their families to choose a preferred medical transportation provider for offsite dialysis and other appointments. One resident with multiple chronic conditions and moderate cognitive impairment requested to use Medical Transportation B but was told by staff that this company could not come on the premises, and her care plan listed only Medical Transportation A. Another resident with end stage renal disease and communication deficits had a family member who requested continued use of Medical Transportation B, which had transported him at home, but the DON stated the facility used Medical Transportation A under contract and did not allow Medical Transportation B. A third resident with encephalopathy, amputation, and ESRD had a family member and POA who preferred Medical Transportation B to maintain consistency, but she was told the parent company would not allow that provider. The Administrator of Medical Transportation B reported being informed by the facility’s Administrator and DON that the facility only used Medical Transportation A, despite facility documents referencing resident rights and resident/responsible party responsibility for arranging transportation.
A resident with dementia, cancer, anxiety disorder, and psychosis, who had impaired cognition and a legal guardian, was transferred to another nursing facility after two resident-to-resident altercations. The care plan required contacting the guardian for all changes, and the EMR documented the transfer, but there was no written transfer or discharge notice to the resident, the guardian, or the State LTC Ombudsman. The guardian reported receiving only a phone call explaining the move and was not given written notice or options for the receiving facility, and the Administrator confirmed that no written notice was completed despite facility policy requiring such notice when safety is endangered.
The facility failed to maintain sufficient nursing staff and continuous supervision in a locked memory care unit and on an adjacent station housing residents with dementia and Alzheimer’s disease. Records showed nearly all memory care residents had dementia, yet staffing patterns routinely assigned one CNA and one medication aide to cover both the memory care unit and another station by day, and only one CNA to both areas at night. A family member reported poor night and weekend care and an occasion when no staff were present in the memory care unit. Staff interviews revealed that the med aide frequently left the unit to pass meds on another hall, leaving residents without direct supervision, and that night-shift CNAs were solely responsible for residents on both units. Surveyors observed periods when no staff were present in the memory care unit while multiple residents were in the common area and moving about the hallway. Several CNAs, LVNs, and the ADON acknowledged that there should always be staff in the memory care unit and that staffing was not adequate to meet residents’ supervision needs.
A resident with dementia, depression, psychotic disorder, and behavioral disturbances, who self‑propelled in a wheelchair and was known to take others’ trays and rearrange dining room furniture, repeatedly directed hateful remarks toward other residents and physically contacted them in the dining room. One resident with osteoarthritis, depression, anxiety, Alzheimer’s disease, and chronic pain reported being struck hard from behind by this wheelchair, developed right shoulder pain lasting about a week, became tearful, and began avoiding common areas out of fear. Another cognitively intact resident reported being yelled at to move and struck on the arm by the same resident, stating that the DON was nearby and attributed the behavior to confusion. A CNA and an LVN acknowledged awareness of the aggressive behaviors and of abuse‑reporting requirements but did not report the incidents to the Administrator, and treatment records showed no documented behaviors despite a physician order to monitor for confusion or aggression each shift. The Administrator and DON denied knowledge of aggressive incidents, and surveyors later observed the aggressive resident in the dining room unlocking and pulling another resident’s wheelchair without staff present, demonstrating a failure to recognize, document, report, and effectively supervise peer‑to‑peer abuse in common areas.
A resident with dementia, depression, anxiety, and chronic pain reported that another cognitively impaired, behaviorally disturbed resident in a wheelchair rammed or bumped her in the dining room and had made hateful verbal remarks to her and others, causing pain and fear. The resident and her responsible party reported the incident and distress to a CNA and an LVN, but the CNA assumed others were handling it and did not notify the Administrator/Abuse Coordinator, and the LVN did not interpret the report as an abuse allegation, did not assess the resident for injury, and did not report it. The social worker was only aware of a verbal disagreement and did not report abuse, and the NP later documented shoulder pain attributed by the resident to another resident’s wheelchair but did not further explore it as possible abuse. Meanwhile, the other resident had documented behavioral issues and an order for behavior monitoring, yet no behaviors were charted and direct observation showed ongoing disruptive actions in the dining room. As a result, the facility failed to implement its abuse policy by not reporting, investigating, or clinically assessing the alleged abuse incident in accordance with its written procedures.
Several residents with severe cognitive and physical impairments did not have their call lights within reach, as required by their care plans and facility policy. Staff interviews confirmed that call lights were found on side tables, in drawers, on the floor, or in a trash can, making them inaccessible. Multiple staff members acknowledged the importance of call light accessibility, but the deficiency was observed across several rooms and shifts.
Multiple staff members failed to follow infection control protocols, including proper hand hygiene and use of PPE, during incontinent care and medication administration for several residents with cognitive impairment and medical devices. Staff used gloves from personal pockets, did not change gloves or sanitize hands between care steps, and did not consistently use gowns as required for enhanced barrier precautions, leading to lapses in infection prevention.
A deficiency was found when the call light system in the bathrooms and bathing areas of multiple residents in the memory care unit was discovered to be non-functional. Staff, including an RN and CNA, confirmed that activating the call lights did not trigger any signal outside the rooms, and several staff members were unaware of the malfunction. The affected residents had significant cognitive and physical impairments, with care plans requiring accessible call lights for assistance, but the facility failed to routinely monitor and ensure the system's functionality as required by policy.
Two residents were not provided with care that maintained their dignity: one was assisted with eating by a CNA who stood while feeding him in a hallway rather than sitting at eye level, and another had her urinary catheter bag left uncovered and visible while in her wheelchair. Staff interviews confirmed awareness of the expectations for maintaining dignity during meal assistance and catheter care, and facility policy requires catheter bags to be covered.
Two medication aides failed to secure blister packs containing personal and medical information for two residents, leaving them visible and unattended on medication carts in hallways. The exposed information included names, medication details, diagnoses, and physician orders, in violation of privacy and confidentiality policies. Facility leadership confirmed that such information must be kept confidential at all times.
A sit-to-stand transfer chair used for multiple residents was found with visible dirt, dried food, and accumulated dust, and staff were unclear about cleaning responsibilities. There was no established cleaning schedule or log for the equipment, and the facility's infection control policy requiring regular cleaning and disinfection was not followed.
A nurse failed to check the gastric residual volume before administering medications via g-tube to a resident with severe cognitive impairment and a gastrostomy, despite physician orders and care plan requirements. The omission was observed directly, and the nurse later acknowledged forgetting the step, which was confirmed as a breach of facility policy by nursing leadership.
Two residents requiring respiratory care did not have their oxygen delivery equipment and breathing masks stored properly when not in use, with one nasal cannula found in a trash can and a breathing mask left unbagged on a bedside table. Staff interviews confirmed that equipment should have been bagged to prevent cross-contamination, but this was not done in accordance with facility policy.
Surveyors found that two residents had medications, including nystatin powder and zinc oxide barrier ointment, left unsecured in their rooms, contrary to facility policy requiring medications to be stored in locked compartments. Staff interviews confirmed that these items should not have been accessible to residents and that their presence was not noticed until the survey. The facility's policy states that only authorized staff may administer medications, highlighting a failure to follow proper storage protocols.
A facility with 150 beds did not employ a qualified full-time social worker for an extended period, instead distributing social services duties among the DON, ADONs, MDS nurse, and Administrator. The previous social worker was terminated, and no replacement was hired, resulting in non-compliance with regulatory requirements for social services staffing.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe cognitive impairment and incontinence did not receive complete incontinent care, as a CNA failed to clean the perineal and external genital areas during a brief change, contrary to the care plan and staff expectations. Staff interviews confirmed that proper care was not provided, and the facility's policy was not available at the time of the survey.
A medication aide failed to administer two prescribed medications—Lactobacillus and D-Mannose—to a resident with multiple chronic conditions, resulting in a medication error rate of 6%. The omission occurred because the medications were not retrieved from the refrigerator during the medication pass, despite being active orders on the MAR. The facility's policy required verification and documentation of each medication, but this process was not followed, leading to the deficiency.
Failure to Honor Resident Choice of Medical Transportation Provider
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to self-determination and choice regarding transportation providers for offsite medical appointments, particularly dialysis. One resident with type II diabetes, heart failure, glaucoma, COPD, and end stage renal disease, who had a BIMS score of 11 indicating moderate cognitive impairment, was care planned to receive dialysis three times a week with transportation by Medical Transportation A. This resident stated she told two staff members she wanted to use Medical Transportation B instead, but was told no and informed that Medical Transportation B could not come on the premises. She reported there was nothing wrong with Medical Transportation A, but expressed a preference for Medical Transportation B because of familiarity. Another resident with cerebral infarction, dysphagia, and end stage renal disease, who had documented communication problems with impaired ability to make self-understood and to understand others, also received dialysis three times a week offsite. His family member, listed as emergency contact and responsible party, reported that he had used Medical Transportation B when at home and requested that the facility use Medical Transportation B for dialysis transport. The DON documented a conversation with this family member, assuring her that the facility had arranged safe and reliable stretcher transportation through Medical Transportation A and reiterating that transportation was already set up. The family member stated she was told Medical Transportation A had a contract with the facility, that there was no contract with Medical Transportation B, and that Medical Transportation B was not allowed in the facility, leaving her feeling she had no choice in the matter. A third resident, with traumatic amputation of the left lower leg, encephalopathy, end stage renal disease, type II diabetes, and COPD, was also care planned to receive dialysis three times a week with transportation by Medical Transportation A and had impaired cognitive function or thought processes. His care plan included interventions to communicate with the resident, family, and caregivers regarding his capabilities and needs, and to keep his routine and caregivers as consistent as possible. His family member and healthcare power of attorney stated they preferred to use Medical Transportation B, which had transported him three times a week for years when he lived at home, and asked staff to call Medical Transportation B for his appointments. She reported being told that Medical Transportation B was not allowed to come into the facility because the parent company would not allow it. The Administrator of Medical Transportation B confirmed that whenever their patients were placed at this facility, they were not allowed to provide transportation and that the facility Administrator and DON had told her they only used Medical Transportation A. Facility education materials and the Resident Admission Agreement referenced resident rights and resident/responsible party responsibility for arranging transportation, but the facility’s practice limited residents’ and families’ ability to choose their preferred transportation provider.
Failure to Provide Required Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide required written notice of transfer or discharge to a cognitively impaired resident, the resident’s legal guardian, and the State Long-Term Care Ombudsman when the resident was moved to another nursing facility. The resident, an older adult with dementia, malignant neoplasm of the prostate, anxiety disorder, and psychosis, had a care plan documenting impaired cognition, short-term memory loss, impaired decision-making, and the presence of a legal guardian. The care plan interventions included contacting the legal guardian for all changes and decision-making. The resident’s admission record listed Guardian E as the emergency contact. On the date of transfer, a nurse’s progress note documented that the resident was transferred to a sister facility, but review of the electronic medical record showed no discharge or transfer notice. Prior to the transfer, the resident had been involved in two resident-to-resident altercations with another resident, one in February and another in early March, with the most recent incident described in a Provider Investigation Report. That report stated the resident propelled himself down the hallway, approached the other resident, and hit him in the chest and left arm, and that the facility had been seeking alternate placement for the other resident since the initial incident. The report further stated that the resident was transferred temporarily to a sister facility until alternate placement for the other resident could be secured. In a telephone interview, the guardian reported being informed by phone that the resident would be moved due to an incident, was told it was not the resident’s fault, and was not given written notice or options for the receiving facility, though she agreed to the transfer. In an interview, the Administrator confirmed she called the guardian, explained the resident had been placed at a sister facility for safety, and acknowledged that no written transfer or discharge notice was completed, despite the facility’s own policy requiring discharge notice as soon as practicable when an individual’s safety would be endangered.
Insufficient Staffing and Lack of Continuous Supervision in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff and continuous supervision in a locked memory care unit and on Station 3, despite a resident population with high dementia and Alzheimer’s diagnoses. On the date of review, records showed 14 residents on the memory care unit, 13 of whom had dementia or Alzheimer’s disease, and 13 residents on Station 3. A family member of a memory care resident with dementia reported poor quality of care on nights and weekends, stating staff did not check on the resident enough at night, left her in the common area too late, and that on one Saturday night there were no staff present in the memory care unit. Staff interviews and observations confirmed that staffing patterns did not ensure continuous presence in the memory care unit. A day-shift medication aide reported she covered both Station 3 and the memory care unit, leaving only one CNA on the unit when she left to pass medications on Station 3, and stated administration had not advised her what to do when the other aide or nurse was busy and she had to leave residents without supervision. A day-shift LVN stated there were not enough staff at night and that during the day there was one CNA and one medication aide for both Station 3 and the memory care unit, while at night only one CNA was assigned to both areas. A CNA working on the memory care unit stated the unit needed two CNAs, that residents were moving most of the day, and that when one resident got up others followed, making supervision difficult. The ADON stated there should be two people at all times in the memory care unit and acknowledged that at night there was only one staff member. Surveyor observations further documented periods with no staff present in the memory care unit. During one observation, five residents were in the common area, one resident stood up, walked to a medication cart, grabbed a blood pressure cuff, and returned to a chair, while other residents walked down the hallway and entered rooms, with a CNA redirecting a resident who had entered the wrong room. On a later evening observation, the LVN was at the Station 3 nurse’s station, another CNA was seen walking toward another station, and no staff were observed in the memory care unit until a CNA entered with the surveyor; no other staff were present on the unit at that time. Multiple night-shift staff, including CNAs and LVNs, reported that only one CNA was assigned to both Station 3 and the memory care unit at night, that CNAs were “running around” answering call lights and doing rounds without taking lunch breaks, and that someone should always be in the memory care unit due to residents’ behaviors, fall risk, and need for supervision. The DON stated the memory care unit should always have a staff member and expressed surprise when informed there were no staff present during the surveyor’s observation, while also stating that 2 nurses and 5 CNAs was appropriate for the census and referencing a contingency staffing policy committing to adequate staffing levels.
Failure to Protect Residents From Peer-to-Peer Verbal and Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse and neglect and to respond appropriately to allegations and observable patterns of aggressive behavior by one resident toward others. A cognitively impaired female resident with dementia, depression, psychotic disorder with hallucinations, and behavioral disturbances was known to self‑propel in a wheelchair, move around the dining room, take other residents’ plates and cups before they were finished, and rearrange dining room chairs. Her care plan identified inappropriate behaviors such as hoarding soiled clothing and linens, placing paper products in briefs, and dragging dining room chairs, with interventions including monitoring and redirection. Despite a physician order to monitor target behaviors of confusion or aggression each shift, the treatment administration records for multiple months showed no behaviors documented, and progress notes for several weeks contained no entries, even though psychological services notes referenced anxiety, agitation, and verbal or physical aggression as focus areas. A female resident with osteoarthritis, depression, anxiety, Alzheimer’s disease, gait abnormalities, and chronic pain, who used a wheelchair and had moderate cognitive impairment, reported that the aggressive resident repeatedly made hateful and nasty remarks to her and other residents and that she was terrified of this resident. She described an incident in the dining room in which she was seated when she felt a hard crash from behind as the other resident in a wheelchair struck her, after which the aggressor wheeled away. The resident reported severe right shoulder pain for about a week following the incident, tearfulness, and avoidance of common areas due to fear of encountering the aggressor. A physiatry NP documented that the resident reported right shoulder/arm pain a few days after another resident accidentally backed into her with a wheelchair, with tenderness over the right upper arm and limited abduction, and noted that pain was improving. The resident’s responsible party stated that when she arrived for a visit, the resident was crying and reported being rammed by the wheelchair, that a bruise developed on the elbow, and that the shoulder bothered the resident for about a week. The responsible party also reported prior hateful remarks from the aggressor, including telling residents to go back to where the hell they came from, and ongoing fear and avoidance behaviors by the injured resident. Another cognitively intact resident reported that about a month earlier, while she was waiting near the kitchen door in the dining room, the same aggressive resident approached in a wheelchair, yelled at her to move, and struck her on the arm with her hand when she did not move. She stated the DON was nearby and believed the DON witnessed the incident, and that the DON told her the aggressor was confused and that this behavior was part of her baseline. This resident began avoiding the aggressor and felt it was not fair that others had to tolerate her behavior. A CNA reported being aware of physical and verbal aggression by the aggressor toward residents and staff and stated that the injured resident had told her the aggressor had hit her and that the injured resident became tearful and refused to enter the dining room when the aggressor was present, preferring to stay in her room. The CNA acknowledged receiving multiple in‑services on abuse and neglect and knowing that all allegations must be reported to the Administrator, but she did not report the allegation because the resident said the nurse and social worker already knew, and she assumed it was being addressed. An LVN recalled the injured resident and responsible party approaching her upset about an altercation in which the aggressor tried to take the resident’s plate and cup while making hateful remarks and bumped her with the wheelchair, but the LVN did not interpret this as an allegation of abuse and did not report it to the Administrator, despite knowing that verbal and physical abuse must be reported. Facility leadership, including the Administrator and DON, stated they were not aware of any aggressive incidents involving the aggressor and other residents, including the two residents who reported being struck. The Administrator acknowledged knowing that the aggressor frequently attempted to clean the dining room and took trays from residents before they finished eating but denied receiving reports of aggression. The social worker stated she was only aware of a verbal altercation between the aggressor and the injured resident and had not been told that the resident was struck or rammed with a wheelchair, and she described the aggressor’s behaviors as consistent with her cognitive impairment. During surveyor observation in the dining room, the aggressor was seen self‑propelling in her wheelchair from table to table, picking up items, pulling on chairs and tables, and then unlocking another resident’s wheelchair brake and pulling that wheelchair backward away from the table while mumbling, with no staff present in the room at the time. Across interviews and record review, there was no evidence that staff consistently recognized, documented, or reported the aggressive resident’s behaviors as potential abuse, nor that they implemented effective supervision or monitoring in the dining room, resulting in repeated unaddressed incidents of verbal and physical aggression toward other residents and the continuation of the aggressor’s presence in common areas despite expressed fear and distress from affected residents.
Failure to Report and Investigate Resident-on-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse, neglect, and exploitation policies by not investigating or reporting allegations of verbal and physical abuse between residents and by not assessing a resident after an alleged abuse incident. One resident, an older female with osteoarthritis, depression, anxiety disorder, Alzheimer’s disease, gait abnormalities, and age-related debility, had a BIMS score indicating moderate cognitive impairment and was care planned for chronic pain and psychosocial risks. Her orders included routine and PRN pain medications and monitoring for pain and depressive features every shift, with documentation showing no pain or behavioral issues noted during the period in question. Despite this, she later reported right shoulder/arm pain and psychological distress related to an interaction with another resident. On a weekend in late February, the resident and her responsible party (RP) reported to LVN A and CNA A that another female resident in a wheelchair had rammed or bumped her in the dining room, causing her to become upset and fearful. The RP stated the resident was crying, reported being rammed by the wheelchair minutes before the RP’s arrival, and that a bruise was developing on the resident’s elbow; the resident later described the impact as a hard crash from behind that caused severe shoulder pain lasting about a week. The resident reported that the other resident had previously made hateful and inappropriate remarks to her and others, and that after the wheelchair incident she avoided common areas and felt terrified of the other resident. CNA A confirmed that the resident told her she had been hit by the other resident and that the resident became tearful and avoided the dining room when the alleged aggressor was present, but CNA A did not report this allegation to the Administrator/Abuse Coordinator, assuming it was already being addressed because the resident said the nurse and social worker were aware. LVN A acknowledged that the resident and RP approached her upset about an altercation with the other resident, reporting that the other resident attempted to take the resident’s plate and cup while making hateful remarks and that the resident said she had been bumped by the wheelchair. LVN A stated she did not interpret this as an allegation of abuse, did not report it to the Administrator, and did not assess the resident for injury, despite knowing that all abuse allegations must be reported to the Abuse Coordinator. The social worker, who participated in a care plan meeting shortly after the incident, reported being aware only of a verbal disagreement and not of any physical contact, and therefore did not report abuse concerns. The NP later documented that the resident reported right shoulder pain and stated another resident had run into her with a wheelchair a few days earlier; he interpreted the event as accidental, did not explore it further as a potential abuse incident, and did not order imaging because the resident reported the pain was subsiding. The other resident involved was an older female with dementia with behavioral disturbances, depression, psychotic disorder with hallucinations, insomnia, muscle weakness, and severe cognitive impairment, who used a wheelchair and could self-propel. Her care plan identified inappropriate behaviors such as storing soiled clothing and linens, placing paper products in briefs, and moving and dragging dining room chairs, with interventions including monitoring and documenting behaviors and observing for early warning signs. She also had an order to monitor target behaviors of confusion or aggression each shift, but the TAR showed no behaviors documented, and there were no progress notes for nearly a month around the time of the incident. However, staff interviews and direct observation showed that she exhibited ongoing disruptive behaviors in the dining room, including moving from table to table, taking items from tables and the floor, pulling on chairs and another resident’s wheelchair, and becoming verbally aggressive when redirected. Despite staff having received in-services on abuse and neglect and the Administrator and DON stating that all allegations should be reported to initiate investigation and ensure resident safety, the Administrator and DON were not informed of the reported physical contact and verbal aggression, and no abuse investigation or immediate assessment of the allegedly injured resident was initiated in accordance with the facility’s Abuse, Neglect, and Exploitation Prohibition policy. An Immediate Jeopardy situation was identified related to these failures, as the facility did not develop and implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property for the residents reviewed. The facility failed to ensure that staff reported the resident’s allegations of being hit or rammed by another resident’s wheelchair and of ongoing hateful verbal remarks to the Abuse Coordinator, failed to assess the resident promptly after the alleged incident despite subsequent reports of shoulder/arm pain, and failed to document and monitor the other resident’s aggressive and disruptive behaviors as ordered. These actions and inactions resulted in the abuse allegation going unreported and uninvestigated, while the resident continued to experience psychological distress and reported fear related to the other resident’s behavior.
Failure to Ensure Call Lights Were Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to several residents, as required by their care plans and facility policy. Observations and interviews revealed that five residents with severe cognitive and physical impairments did not have their call lights within reach while in their rooms. In multiple instances, call lights were found on top of side tables, inside drawers, on the floor, or even in a trash can, making them inaccessible to the residents. Staff interviews confirmed that the expectation was for call lights to be within reach at all times, but this was not consistently followed. The residents involved had significant medical and functional needs, including muscle weakness, lack of coordination, muscle wasting, atrophy, repeated falls, Alzheimer's disease, hemiplegia, diabetes, dementia, and rheumatoid arthritis. Their MDS assessments indicated severe cognitive impairment and dependence on staff for mobility and self-care. Care plans for these residents specifically included interventions to ensure call lights were within reach due to their high risk for falls and inability to independently seek assistance. Staff members, including CNAs, LVNs, RNs, the DON, and the Administrator, acknowledged during interviews that call lights are essential for resident safety and should be accessible at all times. Despite this, the deficiency was observed across multiple rooms and shifts, with staff sometimes unaware that call lights were not properly positioned. The facility's own policy required call lights to be placed within reach of residents' beds or sitting areas, but this was not consistently implemented, resulting in the deficiency.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with hand hygiene and personal protective equipment (PPE) protocols during resident care. In several observed cases, certified nursing assistants (CNAs) did not perform hand hygiene before donning gloves or between glove changes while providing incontinent care. Gloves were sometimes taken from personal pockets, which staff acknowledged could be contaminated due to contact with personal items such as keys and cell phones. During care, gloves were not changed after cleaning soiled areas and before handling clean briefs, and hand hygiene was not performed between glove changes. A licensed vocational nurse (LVN) failed to wear a gown while administering medication via a gastrostomy tube to a resident who had an order for enhanced barrier precautions (EBP), despite signage indicating the requirement for gown and glove use. The LVN acknowledged awareness of the EBP requirement but did not follow the protocol during the observed medication administration. The resident in question had a feeding tube and severe cognitive impairment, and the care plan specified the need for enhanced barrier protection. Additional observations included a CNA not changing gloves or performing hand hygiene while providing incontinent care to a resident with Alzheimer's disease and muscle wasting. The CNA also carried a package of wipes between resident rooms, which was identified as a potential source of cross-contamination. Facility policies required hand hygiene before and after resident contact, after removing gloves or PPE, and after contact with bodily fluids or contaminated equipment. The facility's infection control policies also specified the use of gowns and gloves for residents with indwelling medical devices or feeding tubes. Despite these policies, staff did not consistently adhere to infection control protocols during the observed care activities.
Non-Functioning Call Light System in Memory Care Unit Bathrooms
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that the call light system was functional in the bathrooms and bathing areas of fourteen residents in the memory care unit. During observations, it was found that when the call light switches inside these restrooms were activated, there were no lights outside the residents' rooms to signal that the call lights had been triggered. This issue was confirmed by staff, including an RN, who checked multiple restrooms and found that the call lights were not working. The staff interviewed were not aware of the malfunction prior to the survey and acknowledged the importance of having operational call lights for resident safety and communication. The residents affected had significant medical and cognitive impairments, including severe or moderate cognitive deficits, risk for falls, incontinence, and mobility limitations. Their care plans specifically included interventions to ensure that call lights were within reach and that staff would assist with toileting and other activities of daily living. Despite these documented needs, the non-functioning call light system meant that residents did not have a means to call for assistance while in the restroom, as required by their care plans and the facility's own policies. Interviews with facility staff, including the DON, ADON, and maintenance manager, revealed a lack of awareness and oversight regarding the functionality of the call light system in the memory care unit. The maintenance manager stated he was new and had not personally checked the call lights in that area, assuming they were working because other units' call lights were operational. The facility's policy required routine monitoring of call lights to ensure they were functional, but this was not carried out in the memory care unit, leading to the deficiency.
Failure to Maintain Resident Dignity During Meal Assistance and Catheter Care
Penalty
Summary
The facility failed to maintain resident dignity in two separate instances involving two residents. In the first case, a male resident with muscle wasting and atrophy, who was cognitively intact and dependent on staff for eating, was observed being fed by a CNA who remained standing while assisting him with lunch in the hallway, rather than sitting at eye level and in the dining area. The CNA began feeding the resident while waiting for another staff member, and only stopped when instructed by a colleague to move the resident to the dining area. Both the CNA and other staff interviewed acknowledged that standing while feeding a resident does not provide dignity and gives the impression of being rushed. In the second instance, a female resident with chronic kidney disease and an indwelling urinary catheter was observed in her wheelchair at her doorway, with her catheter bag exposed and not covered by a privacy bag. The resident, who was cognitively intact, expressed that it would be preferable for her urine bag not to be visible as she was about to leave her room. The CNA responsible for transferring her to the wheelchair admitted awareness that the catheter bag was not covered and stated that a privacy bag should have been used to prevent embarrassment. Interviews with the DON, ADON, and Administrator confirmed that staff are expected to sit beside residents during meals to promote dignity and to ensure catheter bags are covered to maintain privacy. Facility policy also requires catheter bags to be stored in privacy bags to uphold resident dignity. These failures resulted in residents not being treated with the respect and dignity required by facility policy and regulatory standards.
Failure to Protect Resident Privacy and Confidentiality of Medical Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of personal and medical records for two residents. In the first instance, a medication aide (MA D) left a blister pack containing a resident's medical information at the side of the medication cart, with the information visible to anyone passing by in the hallway. The blister pack displayed the resident's name, medication details, prescription number, dosage, frequency, physician's order, diagnosis, and pharmacy name. The medication cart was left unattended while the aide administered medications in a resident's room, leaving the information exposed for several minutes. In the second instance, another medication aide (MA E) left a blister pack with a different resident's medical information on top of a medication cart parked in a hallway leading to the memory care unit. The cart was unattended, and the blister pack was visible to anyone in the hallway. The information on the blister pack included the resident's name, medication details, prescription number, dosage, frequency, physician's order, diagnosis, and pharmacy name. The aide acknowledged that the information should have been secured inside the cart before leaving it unattended. Both residents involved had significant medical histories, including chronic obstructive pulmonary disease and hypothyroidism, with one resident being cognitively intact and the other having severe cognitive impairment. The facility's staff, including the Director of Nursing, Assistant Director of Nursing, and Administrator, confirmed that personal and medical information should not be left exposed and must be kept confidential, as outlined in the facility's policy on resident rights, dignity, and privacy.
Failure to Maintain Clean and Sanitary Resident Transfer Equipment
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment by not ensuring that a sit-to-stand transfer chair was thoroughly cleaned and sanitized. During an observation, a CNA was seen pushing the transfer chair, which had visible dirt, dried food particles, and accumulated dust on its footrest and base. The CNA was unsure who was responsible for cleaning the equipment. The ADON, present at the nurses' station, acknowledged the importance of cleaning resident equipment but indicated that a maintenance order would be needed to address the issue. The DON confirmed there was no set cleaning schedule for the sit-to-stand transfer chair, despite it being used for multiple residents and requiring cleaning after each use. Further interviews revealed that the ADON personally cleaned the chair after the issue was identified, noting the presence of hair, food, and dirt that had become gummy when cleaned, indicating it had not been maintained. The DOS, responsible for maintenance, laundry, and housekeeping, stated that housekeeping staff were responsible for cleaning such equipment but confirmed there was no routine cleaning log in place. The interim administrator also stated that a schedule for cleaning resident equipment was not in effect at the time of the deficiency. Review of the facility's infection control policy indicated that equipment should be maintained and cleaned according to policy and manufacturer recommendations, which was not followed in this instance.
Failure to Check Gastric Residual Before G-Tube Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to check the gastric residual volume before administering medications via a gastrostomy tube (g-tube) to a female resident with severe cognitive impairment and a history of gastrostomy. The resident's care plan and physician orders specifically required that gastric residuals be checked every shift and prior to medication administration to prevent complications such as aspiration. During direct observation, the LVN prepared and administered the resident's medications through the g-tube without performing the required residual check, despite having the necessary supplies and knowledge of the correct procedure. The resident's medical record indicated a significant risk for aspiration related to the g-tube, and the care plan included interventions to check gastric residuals as a preventive measure. Interviews with the LVN and facility leadership confirmed that the expected protocol was not followed, and the LVN acknowledged forgetting to perform the check due to nervousness. The facility's policy also mandated residual checks to prevent complications for residents with enteral feeding tubes.
Improper Storage of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required respiratory support, as evidenced by improper storage of respiratory equipment. For one resident with a respiratory disorder who was on continuous oxygen therapy via nasal cannula, the nasal cannula was observed inside a trash can and not bagged when not in use. This resident's care plan and physician's orders specified the need for supplemental oxygen and proper monitoring, but the equipment was not handled according to professional standards or facility policy. Another resident, diagnosed with pneumonia and severe cognitive impairment, had a nebulization machine with a breathing mask that was not bagged when not in use. The resident was unable to recall the last use of the equipment, and the mask was left exposed on the bedside table. The care plan for this resident included following orders for respiratory illness treatment, and physician's orders specified the use of inhaled medication as needed. Interviews with staff, including an LVN, DON, and ADON, confirmed that the nasal cannula and breathing mask should have been bagged when not in use to prevent cross-contamination and infection. The facility's policy on respiratory treatment and infection control required proper cleaning and storage of respiratory equipment, which was not followed in these instances.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored in locked compartments, as required by professional standards. During observations, it was found that a male resident with obesity and muscle weakness, who was cognitively intact and incontinent, had three bottles of nystatin powder and barrier ointment stored in a basket at his sink inside his room. The resident confirmed that these items had been in his room for some time, alongside personal care items, and that staff were aware of their presence. A female resident, also cognitively intact and incontinent, was found to have a tube of barrier ointment containing zinc oxide left on top of her table at the foot of her bed, visible from the hallway, while she was not present in the room. Staff interviews confirmed that medications, including medicated ointments and powders, should not be accessible in residents' rooms due to the risk of misuse. Staff acknowledged that these items should have been stored in medication carts or secured drawers, and that they were not aware of the presence of these medications in the residents' rooms until the surveyor's observation. The facility's policy on medication administration and management specifies that only authorized medical and licensed nursing staff are permitted to administer medications ordered by a physician. Despite this policy, the presence of nystatin powder and barrier ointment in residents' rooms indicated a lapse in adherence to proper medication storage protocols, as staff failed to remove or secure these items, allowing them to remain accessible to residents.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility, with a licensed capacity of 150 beds, failed to employ a qualified full-time social worker from 6/25/25 to 8/30/25. Record review confirmed that the previous social worker was terminated on 6/25/25, and no replacement was hired during the period under review. Interviews with the Assistant Directors of Nursing (ADONs) and the Director of Nursing (DON) revealed that, in the absence of a social worker, social services duties such as arranging dental, podiatry, and vision appointments were managed by the ADONs, MDS nurse, Administrator, and DON. The DON also handled discharge planning, home health arrangements, and medication coordination for discharged residents. The facility's job description for the Social Services Director specifies responsibility for planning, organizing, developing, and directing the overall operation of the Social Services Department in compliance with federal, state, and local regulations. Despite these requirements, the facility did not have a qualified full-time social worker on staff during the specified period, and social services responsibilities were distributed among other staff members.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Incomplete Incontinent Care Provided to Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide complete incontinent care to a male resident with severe cognitive impairment, dementia, and type 2 diabetes. The resident was frequently incontinent of bladder and always incontinent of bowel, requiring substantial assistance with toileting and hygiene. During an observed care episode, the CNA removed the resident's saturated brief, cleaned only the buttocks with wet wipes, and did not clean the perineum or external genitalia before applying a new brief. This action was inconsistent with the resident's care plan, which required routine rounding and thorough cleaning to minimize urinary tract infections. Interviews with staff confirmed that proper incontinent care should include cleaning the entire perineal, genital, and anal areas every two hours and as needed. The CNA acknowledged the omission, and other staff, including the RN, medication aide, and DON, confirmed that incomplete cleaning could lead to skin breakdown and infection. The facility's policy on incontinent care was not provided prior to the survey exit.
Medication Error Rate Exceeds 5% Due to Omitted Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6% error rate during the survey period. Specifically, two medications—Lactobacillus and D-Mannose—were not administered to a resident as ordered. Observation revealed that the medication aide (MA) prepared and dispensed nine medications to the resident but omitted the two required medications, which were later found to be stored in the refrigerator and not retrieved during the medication pass. The MA confirmed during interview that these medications were active orders and acknowledged not administering them because they were not taken out of the refrigerator. The resident involved had multiple diagnoses, including mood disorder, hypertension, presence of a cardiac pacemaker, congestive heart failure, and a history of urinary tract infection. The facility's policy required staff to verify each medication against the Medication Administration Record (MAR) and to check off each medication as it was dispensed. The Director of Nursing (DON) stated that following this process would have prevented the omission, as the system highlights each medication as it is administered. The failure to follow established procedures led to the omission of the two medications.
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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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