Paradigm At Woodwind Lakes
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 7215 Windfern Rd, Houston, Texas 77040
- CMS Provider Number
- 675085
- Inspections on file
- 60
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at Paradigm At Woodwind Lakes during CMS and state inspections, most recent first.
The facility failed to verify and implement resident advance directives and DNR status at admission, resulting in conflicting documentation and treatment that did not align with residents’ expressed wishes. One resident with hospital records and a portal summary clearly indicating DNR status was admitted without an admission packet, listed as full code in the EMR and care plan, and received CPR after being found unresponsive because staff relied on the EMR banner and did not review supporting DNR documents or contact the POA to resolve discrepancies. Another resident with hospital DNR documentation and a completed OOH-DNR form was care planned as full code, and physician orders alternated between full code and DNR without timely clarification or documentation of discussions with the responsible party. Interviews with the DON, social worker, admissions coordinator, marketer, NP, and medical director showed that no single role was clearly accountable for reconciling advance directives at admission, the DON did not review clinicals, the social worker only verified code status at the 72-hour care plan, and the admission packet containing advance directive acknowledgements was not consistently provided or reviewed with responsible parties, leading to systemic failures in honoring residents’ code status.
A resident with multiple medical conditions and mild cognitive impairment was admitted with a family member holding POA present, but the facility failed to provide or review the admission packet that includes resident rights, rules, responsibilities, charges, and advance directive information. The EMR contained no admission packet or agreement, and the advance directives section was left blank. The Admissions Coordinator acknowledged that no packet was created or given, did not review packet contents with residents or representatives, and intentionally withheld the packet pending POA confirmation, despite POA documentation being available. The family member reported never receiving any rights information or documentation, while the Administrator stated the packet is the primary means of communicating rights and resident wishes; later, the resident received CPR despite having DNR wishes handled by the hospital.
A resident with severe dementia, impaired communication, gait instability, and a history of wandering and walking into objects was care planned for frequent checks and supervised ambulation. In the memory care dining area, a CNA placed the resident on a couch and left to care for another resident without handing off supervision, while another CNA and an LVN were at the nurses’ station charting and not maintaining direct visual observation of the dining room. The resident, who was known to walk continuously and not remain seated, sustained an unwitnessed fall and was later found on the floor; a hematoma developed on the right forehead, and the resident was sent to the hospital. Leadership and staff acknowledged that residents in memory care required constant supervision and that the nurses’ station did not allow full visibility of the dining room, but supervision expectations and facility policies on dementia care, fall management, and safety were not followed at the time of the incident.
A resident with severe cognitive impairment, neurogenic bladder, and an indwelling Foley catheter experienced a progressive slit on the penis and urine leakage into an incontinent brief due to inadequate catheter monitoring and care. Orders and the care plan required every-shift assessment of the catheter site for redness, irritation, urethral erosion, leakage, and urine characteristics, but nursing documentation showed no reported issues while the penile slit enlarged from a small, non-bleeding area to a beefy red, bleeding wound extending from the meatus down the shaft. During observed care, the resident’s brief was saturated with urine, dressings were wet and non-adherent, and the catheter tubing contained sediment with cloudy, sediment-filled urine in the bag. Staff interviews revealed that some staff had known about the slit for weeks, the assigned nurse had not assessed the penis or recognized leakage despite making rounds, and the NP had not been informed of the worsening condition or catheter leakage, demonstrating failures to monitor, recognize, and report catheter-related complications.
Two residents did not receive fully developed and implemented person-centered care plans consistent with their assessed needs. One resident with dementia, parkinsonism, and bilateral hand contractures had physician orders for a restorative program that might have included a resting hand splint and specific ROM/stretching interventions, but these device-based interventions were not incorporated into the care plan and were inconsistently applied, with staff unable to locate the devices or documentation of their use. Another resident with advanced dementia, severe cognitive impairment, gait impairment, and documented wandering had a care plan calling for supervision and safety measures, yet she continued to wander with frequent loss of balance and sustained an unwitnessed fall with a facial hematoma, while staff reported only general supervision and non-skid socks as active interventions and uncertainty about specific supervision measures in the care plan.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with severe cognitive and physical impairments was transferred by a single CNA instead of the required two-person assist, resulting in the resident's head striking the wall. The CNA admitted to performing the transfer alone, contrary to the care plan and facility policy, and staff assessments confirmed the resident sustained a minor injury. Documentation and interviews verified that the transfer was not conducted according to established procedures.
A resident with end-stage renal disease and multiple comorbidities did not have required Dialysis Hand Off Communication Report forms completed or properly maintained for the majority of her dialysis sessions. Despite physician orders and facility policy mandating the use of these forms to ensure communication between facility staff and the dialysis center, the forms were either missing or incomplete, and oversight by nursing management was inconsistent.
A resident with multiple chronic conditions developed a sacral wound that progressed to a stage 4 pressure injury with infection and severe sepsis after staff failed to follow wound care orders and did not consistently document or perform required treatments. The wound worsened over several weeks, and the resident was ultimately transferred to the hospital after family intervention.
Two residents dependent on staff for ADLs did not consistently receive required showers, baths, or nail care, as evidenced by missed scheduled care and observations of poor hygiene. Staff interviews and documentation revealed lapses in following care plans and facility policy, resulting in unaddressed grooming and hygiene needs.
A Wound Care Nurse failed to change gloves between cleansing a wound and applying treatment and dressing for a resident with a stage 3 pressure ulcer, contrary to facility policy. The resident, who was fully dependent and had multiple health issues including sepsis and chronic pain, received wound care without proper infection control practices, as observed by surveyors.
Two residents requiring oxygen therapy did not receive care consistent with physician orders and facility policy. One resident received continuous oxygen without a current physician order, while another received oxygen at a higher flow rate than ordered. Staff interviews and record reviews confirmed these discrepancies, and the facility's policy requiring verification and documentation of oxygen therapy was not followed.
Surveyors identified that the facility's medication error rate exceeded five percent due to three errors involving two residents. In one case, a nurse administered a stool softener and a multivitamin with minerals instead of the specific medications ordered for a resident with dementia and constipation, citing stock issues. In another case, a medication aide applied a new Rivastigmine patch before removing the old one for a resident with dementia, contrary to facility policy and physician orders. These errors were attributed to staff not following established medication administration protocols.
Two residents in a facility experienced discomfort due to drafty windows in their room, which were not properly sealed, allowing cold air to enter. Despite complaints and the provision of extra blankets, the issue was not addressed promptly, affecting the residents' comfort and safety. The residents, both with severe cognitive impairments and other health conditions, reported feeling cold, and staff interviews confirmed awareness of the problem.
The facility failed to provide palatable and appetizing meals, as observed during a survey. The lunch meal served was bland and poorly prepared, with mushy pasta and chewy squash. Residents expressed dissatisfaction, and there was an increase in requests for alternative meals. The Dietary Manager noted the cook's inexperience and the need for more staff and training to improve meal quality.
The facility failed to follow professional standards for food service safety, as observed in their kitchen. Drinks were stored in the fridge without lids or labels, a pitcher of chopped fruit lacked a date or label, and a bin of flour was not completely sealed. The Assistant Dietary Manager acknowledged these oversights, which could risk foodborne illness.
A resident with multiple health conditions, including dementia and frequent incontinence, did not receive appropriate incontinent care, as a CNA cleaned from back to front and failed to change gloves, contrary to facility policy. This action posed a risk of urinary tract infections, as confirmed by staff interviews and facility procedures.
A medication error occurred when a resident was given blood pressure medications outside of the physician's prescribed parameters, resulting in a 7% medication error rate at the facility. The resident, with a history of hypertension, received Isosorbide and Carvedilol despite a blood pressure reading below the hold threshold. The error was acknowledged by the medication aide, who had recently started working at the facility, and was reported to the nursing staff. The facility's policy required adherence to physician orders, and the management team was responsible for ensuring compliance.
A resident in an LTC facility received blood pressure medications outside the prescribed parameters, leading to a significant medication error. The resident, with a history of heart failure and hypertension, was given Isosorbide and Carvedilol despite having a blood pressure of 107/71 and a heart rate of 67, which were outside the ordered parameters. The error was realized post-administration, and the nursing staff acknowledged the potential risks involved.
A resident with multiple medical conditions and frequent incontinence did not receive proper infection control during care. CNA A failed to change gloves and perform hand hygiene after cleaning the resident's perineal area, risking cross-contamination. Interviews with staff confirmed the breach, and facility policies were reviewed, highlighting the need for proper glove removal and handwashing.
The facility failed to maintain a clean and sanitary environment in a secured unit, with observations of dirty, sticky floors in the hallway, dining room, and activity room. A resident was seen walking barefoot on the dirty floor. The Housekeeping Supervisor and Maintenance Manager acknowledged the issues, citing inadequate oversight and accountability for floor cleanliness. The Director of Nursing was aware of the problem and mentioned plans to address it.
Failure to Verify and Implement Resident Advance Directives and DNR Status at Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ advance directives were accurately identified, clarified, and implemented upon admission, resulting in discrepancies between documented code status and residents’ expressed wishes. For one resident (CR#1), hospital records and the admission portal summary clearly indicated a DNR status and receipt of a living will, yet the facility’s baseline care plan and EMR listed her as full code. Her advance directives section in the facility record was blank, and there was no admission packet or agreement on file. Physician orders initially documented her as full code, and although a physician progress note later reflected both “Full code” and “Advance Directives DNR,” no clear, timely clarification was obtained. Staff did not review the miscellaneous tab in the EMR for DNR paperwork, and no one contacted the POA to reconcile conflicting documentation. On the morning of the event, CR#1 was found unresponsive with no palpable pulse. Nursing staff confirmed her status as full code using the EMR banner and initiated CPR, which continued until EMS arrival and transport to the hospital. EMS continued resuscitative efforts, including intubation and mechanical CPR, until the POA notified hospital staff that the resident’s wishes were DNR, at which point resuscitation was stopped and the resident was pronounced deceased. Interviews with family and the hospital case manager confirmed that the resident had chosen DNR status during her hospital stay and that DNR documentation had been sent to the facility prior to admission. The facility did not clarify the discrepancy between hospital DNR documentation and internal full-code orders before the change in condition occurred. For another resident (Resident #1), hospital nephrology notes and the hospital transfer cover page documented a DNR code status, and an OOH-DNR form had been completed, signed by the legal guardian, witnessed, and notarized. However, the facility’s care plan identified this resident as full code, and physician orders alternated between full code and DNR on multiple dates, with changes verified only by medical record review and without documented prior clarification. The medical director’s signature on the OOH-DNR form was delayed, and there was no documentation addressing the resident’s advance directives prior to a late social worker note confirming the RP’s wish for the resident to remain DNR. Interviews with the DON, social worker, admissions coordinator, marketer, NP, and medical director revealed that no specific staff member was clearly responsible for verifying and reconciling advance directives at admission, that the DON did not review clinicals before or after admission, and that the admissions coordinator did not provide or review the admission packet containing advance directive acknowledgements with CR#1’s POA. These systemic gaps led to residents being treated as full code despite prior DNR designations and without timely clarification of discrepancies in their advance directive documentation. The facility’s own staff acknowledged that the admission process for advance directives was fragmented and that responsibilities were unclear. The DON stated there was no specific staff responsible for ensuring residents’ wishes and code status were accurately entered at admission and that she did not investigate CR#1’s code status concerns or audit advance directives after the incident. The social worker confirmed she only verified code status at the 72-hour care plan and did not review admission documentation or contact CR#1’s POA before the resident’s death. The admissions coordinator admitted she did not send an admission packet to CR#1’s POA, did not review its contents with responsible parties, and did not recognize that the packet contained advance directive acknowledgements. The administrator and medical director both described failures in communication, documentation, and timely clarification of discrepancies, and the facility later identified additional residents whose DNR status could not be confirmed and whose code status had been changed to full code while verification was pending.
Failure to Provide Admission Packet and Communicate Resident Rights and Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident, both orally and in writing, of her rights, rules, responsibilities, and facility policies at the time of admission. The resident was an elderly female admitted with diagnoses including UTI, history of colon cancer and large intestine, hypertension, irregular heartbeat, presence of a pacemaker, and mild cognitive impairment, with a BIMS score of 12/15 indicating moderately impaired cognition. Her face sheet listed a family member as Emergency Contact and POA for healthcare, and her advance directives section was blank. Progress notes documented that she arrived in the evening by EMS, was A&O x2, oriented to the room and equipment, and did not voice concerns at that time. However, the electronic medical record contained no admission packet or admission agreement for her. Interviews with facility staff revealed inconsistent and incomplete practices regarding the admissions packet, which contained resident rights, rules governing resident conduct, responsibilities, charges, and advance directive information. The Administrator stated that resident rights were communicated through the admissions process and packet, and that the Admissions Coordinator and Marketing were responsible for completion of the packet, which should be provided before or at admission and completed within 72 hours. The DON similarly stated that the packet was sent prior to arrival and completed shortly after admission. In contrast, the Admissions Coordinator initially described her role as getting the room ready and ensuring a good stay, and stated she was not responsible for reviewing documentation. She later stated she was responsible for the admission packet, usually completed after admission and provided via email or in person within 48 hours, but that she did not review the packet contents with residents or their representatives. For this resident, the Admissions Coordinator acknowledged that no admission packet was created or provided, and that the resident’s POA, who was present at admission, never received the packet or any communication of resident rights or other packet contents. She stated she intentionally did not send the packet because she had not yet confirmed the POA status, even though the executed POA was included in documentation received before and after admission. The family member/POA reported that the resident was very confused and distressed on admission, repeatedly stating that people were trying to kill or harm her, and that the family member never received an admission packet or any documentation of rights or other information. The Administrator stated that failure to deliver or communicate the contents of the admissions packet could leave residents unaware of their rights and the facility unaware of residents’ wishes. The record also showed that the resident’s advance directives were not documented in the facility record, and on a later date she received CPR when unresponsive despite her wishes being DNR, with the hospital having handled the DNR paperwork.
Unwitnessed Fall and Head Injury Due to Inadequate Supervision in Memory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a cognitively impaired resident in the memory care unit. The resident was an elderly female with dementia with psychotic disturbance, severe cognitive impairment (BIMS score of 00), altered mental status, restlessness and agitation, gait impairment, lack of coordination, and a history of unintentionally walking into objects and removing footwear. Her care plan identified ADL deficits, the need for staff to anticipate needs and provide prompt assistance, supervision with one staff for walking in the room and corridor, limited assistance for locomotion on and off the unit, frequent checks during high‑risk times, maintaining safety during increased wandering, and offering engaging activities to reduce restlessness. The care plan also noted impaired communication, risk for further decline and injury, and the need to reduce environmental stimuli and use communication tools the resident could understand. On the day of the incident, the resident was wandering in the memory care dining room and was known by staff to walk continuously, not remain seated, and be unable to communicate needs verbally. CNA A reported placing the resident on a couch in the dining area and then leaving to provide care to another resident without notifying other staff or providing a handoff of supervision, despite the expectation that residents in the memory care unit be supervised at all times and that staff verbally pass on supervision responsibilities before leaving an area. CNA B stated she was at the nurses’ station charting and was not directly observing the resident, did not see or hear the fall, and was unaware of the exact whereabouts of other staff. She reported that she had been charting for about five minutes before noticing the resident on the floor in the dining room and was unsure how long the resident had been on the floor. LVN A stated she was seated at the nurses’ station documenting, could only see a portion of the dining room from that position, and was notified by CNA B that the resident was on the floor. The fall was unwitnessed, and the resident was found on the floor in a seated position on her bottom in the dining room. Initial assessment by LVN A documented stable vital signs and no visible injuries or pain at that time, and the environment around the fall was noted to have no notable findings. Later, swelling and a nodule/hematoma developed on the right side of the resident’s forehead, with subsequent discoloration to the right side of the face above the eyebrow, below the eye, and toward the nose. The resident was sent to the hospital, where imaging and tests were described as reassuring, and instructions were given to ice the hematoma. Facility leadership, including the ADON, DON, and Administrator, stated that residents in the memory care unit, and this resident in particular, required constant or continuous supervision due to wandering, inability to ensure their own safety, and communication deficits, and that staff were expected to maintain direct visual observation and communicate supervision coverage. Staff interviews and observations confirmed that at the time of the incident, the resident was not under continuous direct observation, supervision responsibilities were not properly handed off, and the nurse’s station position did not allow full visibility of the dining room, leading to the unwitnessed fall and resulting head injury. Subsequent observation of the resident by the surveyor showed that she ambulated independently but experienced brief losses of balance every few steps or when stopping, did not respond verbally, and did not allow staff to assist for more than a few seconds before moving away. LVN C confirmed that the resident never sat still, including during meals, did not communicate verbally, and required continuous direct observation to ensure safety. The facility’s own policies on Dementia Care, Fall Management, and Standards of Care required person‑centered care, individualized fall prevention plans, supervision during high‑risk activities such as ambulation, and safety measures to prevent accidents and injuries. Despite these policies and the resident’s documented risks and care plan interventions, staff actions and inactions at the time of the incident resulted in the resident being unsupervised in the dining room, an unwitnessed fall, and a hematoma to the forehead requiring hospital evaluation.
Failure to Monitor and Manage Indwelling Catheter Leading to Worsening Penile Injury and Urine Leakage
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and monitoring for a male resident with an indwelling urinary catheter, resulting in worsening penile injury and leakage of urine into his incontinent brief. The resident had significant medical conditions including hypertension, stage 3 pressure ulcers, neurogenic bladder, obstructive and reflux uropathy, and used an indwelling catheter. His MDS showed severe cognitive impairment, total dependence for toileting, and incontinence of bowel and bladder. His care plan and physician orders required staff to follow catheter-related orders, monitor the catheter site every shift for signs of infection, irritation, urethral erosion, and leakage, and to monitor urine characteristics and report abnormalities to the physician. Surveyor review of prior documentation showed that during an earlier survey, the resident’s penis had a small slit measuring 0.3 cm by 0.1 cm with slight redness, and there was no leg strap or Statlock securing the catheter. CNAs at that time reported they had not previously seen the slit. Despite ongoing orders to monitor for complications each shift, the March MAR entries indicated nurses signed off that there were no issues with the Foley and skin area. However, during a later observation of catheter and incontinent care, the resident’s penis was found to be slit from the meatus down the shaft, with a beefy red color and fresh bleeding. The slit had increased in size to 1.5 cm by 0.5 cm. When the area was wiped, the wipes showed a substantial amount of blood. Staff interviews indicated that the slit had been present and known to some staff for weeks, but they described it as smaller and not bleeding previously. During the same observation, the resident’s brief was saturated with urine, the wetness indicator was not visible, and the wound dressing near the buttock was wet and non-adhesive, with a second dressing soaked. The Foley tubing contained smears of sediment with no urine visible in the tubing, and the Foley bag held cloudy urine with a significant amount of sediment. The nurse assigned to the resident stated he had made rounds twice that day but had not noticed Foley leakage or assessed the penis, and he acknowledged he was aware of the slit from prior orientation but believed it was regular wear and tear from Foley use. He also stated he was not aware of the leakage until he saw the soaked brief and sediment in the tubing and bag, and he did not identify when to obtain an order to flush the catheter. The NP later reported she had not been informed that the slit had worsened, had not been notified of leakage or balloon issues, and had not given the ointment order the nurse described. Other staff, including CNAs, the ADON, DON, and Corporate Nurse, confirmed the slit had been smaller previously, that the Foley had been leaking onto the brief, and that sediment and potential clogging could cause leakage and skin breakdown, but these changes and complications were not consistently recognized, monitored, or reported as required by the resident’s orders and care plan.
Failure to Integrate and Implement Contracture and Wandering Interventions in Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents whose needs had been identified in their assessments. For one male resident with Alzheimer’s disease, parkinsonism, stroke history, muscle weakness, and dependence in ADLs, the comprehensive assessment and care plan identified bilateral hand contractures and risk for skin breakdown, pain, and worsening contractures. The care plan interventions focused on keeping contractured areas clean and dry, providing PROM without forcing the joints, monitoring for pain and stiffness, and providing medications and treatments as ordered. However, the resident’s physician orders included a restorative nursing program that might have included a left resting hand splint and specific ROM and stretching exercises to prevent further contractures, and these splint/hand device interventions were not incorporated into the care plan. Observations and interviews showed that the ordered hand splint/hand roll interventions were not consistently implemented. During observation, the resident was noted to have contractures in both hands with no splint or hand roll in place, and the resident reported that staff applied the devices only when they wanted and that he had not received them that day. The assigned RN stated he had not seen any hand roll in place, acknowledged the resident was supposed to have one, and indicated that restorative aides or CNAs were responsible for applying them. CNAs and restorative aides confirmed the resident was supposed to have “carrots” or rolled towels in both hands for specified on/off intervals, but reported that the devices were not present in the room at times, that they relied on restorative aides or CNAs to apply them, and that documentation of this care was inconsistent. Facility leadership, including the DON, ADON, and MDS Coordinator, acknowledged that the hand device intervention was not on the care plan, that restorative documentation was not integrated into the electronic plan of care, and that they could not locate documentation showing the ordered intervention had been consistently provided. The deficiency also involves a female resident with dementia with psychotic disturbance, gait impairment, lack of coordination, altered mental status, restlessness, and agitation, who had severe cognitive impairment (BIMS score of 0), fluctuating inattention and disorganized thinking, and documented wandering behavior. Her care plan identified ADL deficits, need for staff to anticipate needs and provide prompt assistance, limited assistance for locomotion, supervision for walking, PROM as needed, and a history of unintentionally walking into objects. Interventions included frequent checks, maintaining safety during increased wandering, offering engaging activities, reducing environmental stimuli, using communication tools she could understand, and addressing her history of removing footwear. Despite these care-planned needs, the resident experienced an unwitnessed fall in the dining room after wandering, later presenting with a hematoma and discoloration on the right side of the face that required hospital evaluation. Subsequent observation showed the resident ambulating independently with frequent brief losses of balance, not responding verbally, and continuing to walk away from staff attempts to assist. Staff interviews indicated that CNAs and nursing staff recognized the resident as nonverbal, continuously walking, not remaining seated, and at high fall risk, and that she required staff to watch her while walking. However, staff also reported there were no specific interventions beyond general supervision and non-skid socks to address her constant movement and wandering, and one CNA was unsure whether the care plan specifically included supervision interventions. Leadership interviews confirmed that staff were expected to follow care plans, that the resident was care planned for supervision due to wandering and fall risk, and that failure to follow or individualize care-planned interventions could result in residents not receiving necessary services. The care plan was only updated after the fall to add non-skid socks, indicating that at the time of the incident, the care plan and its implementation did not fully address the resident’s persistent wandering and supervision needs as identified in her assessments.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident who required extensive assistance from two staff members for transfers. The resident, a female with severe cognitive impairment, multiple physical and neurological diagnoses, and limited mobility, was transferred by a single CNA instead of the required two-person assist. During the transfer from her wheelchair to her bed, the CNA lifted the resident alone, resulting in the resident's head bumping against the wall. The CNA admitted to performing the transfer alone, despite the care plan specifying the need for two staff, and stated that he had done so in the past. The incident was witnessed by the resident's roommate, who reported being awakened by the sound of the resident's head hitting the wall. The CNA immediately reported the incident to the unit manager and nurse, who assessed the resident and found a small raised area on the back of her head but no bleeding or discoloration. The resident's vital signs and mentation were at baseline, and she did not display signs of pain or distress during the assessment. The facility's policy and care plan documentation confirmed that the resident required a two-person assist for transfers, and this information was available in the resident's chart and point of care system. Interviews with staff, including the CNA, nurses, unit manager, and director of nursing, confirmed that the transfer was not performed according to the resident's care plan and facility policy. The CNA acknowledged not following the required procedure and indicated that he had previously transferred the resident alone. The facility's transfer and lift policy emphasized the importance of individualized care plans and appropriate staff assistance to ensure resident safety during transfers, which was not adhered to in this case.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the Dialysis Hand Off Communication Report forms, which are intended to facilitate ongoing communication between the facility and the dialysis center, were either not completed or were incomplete for 22 out of 23 opportunities. Record review showed that for the months reviewed, there were no report forms accounted for in May and only five out of nine forms in July, with only one of those being fully completed. The process required the charge nurse to complete the top portion of the form before sending the resident to dialysis, and the dialysis center to complete the bottom portion upon return, but this process was not consistently followed. The resident involved was a female with multiple diagnoses, including end-stage renal disease, diabetes with neuropathy, heart failure, and atrial fibrillation. She was cognitively intact and required assistance with activities of daily living. Her care plan and physician orders specified regular dialysis sessions and the need for pre- and post-dialysis vital signs. Despite these orders and the facility's policy requiring the use of the Dialysis Communication Form, the forms were not properly completed or maintained in the resident's medical record as required. The interim DON confirmed the process and acknowledged that it was the unit manager's responsibility to ensure compliance, but this was not consistently done.
Failure to Follow Wound Care Orders Resulting in Stage 4 Pressure Injury and Sepsis
Penalty
Summary
Facility staff failed to provide pressure ulcer care and prevent new ulcers from developing for a resident with multiple comorbidities, including heart disease, respiratory failure, COPD, diabetes, and end-stage renal disease. The resident was admitted without pressure ulcers but was identified as being at risk for skin breakdown. Despite care plan interventions such as weekly skin checks and use of a pressure-reducing device, the resident developed a sacral wound during her stay. Physician orders for wound care were not followed on multiple documented occasions, as evidenced by gaps in the treatment administration record. The wound, initially noted as a small opening, progressed in size and severity over several weeks. Documentation and interviews revealed that wound care was either not performed or not documented as performed on several dates, and the wound deteriorated to an unstageable and then stage 4 pressure injury. The resident's family ultimately intervened, resulting in the resident's transfer to the hospital, where she was diagnosed with a stage 4 pressure injury, infection, and severe sepsis. Interviews with facility staff, including the ADON, DON, wound care nurses, and other nursing staff, confirmed that there was a failure to follow physician orders for wound care and to document treatments provided. Staff acknowledged the risks associated with not following wound care protocols and the importance of documentation. The wound care nurse responsible for the resident's care was no longer employed at the facility at the time of the investigation, and staff reported recent in-services on wound care and skin assessments.
Failure to Provide Consistent ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, a male with Alzheimer's Disease, dementia, muscle weakness, and impaired mobility, was dependent on staff for all ADLs. Despite a care plan goal for the resident to be well-groomed and clean, observations revealed greasy hair, dirty sheets, and the resident reported not receiving showers or baths three times a week as required. Review of shower sheets confirmed that the resident missed 13 scheduled baths over a two-month period, with only a few bed baths documented and some refusals noted. Staff interviews indicated a lack of clarity regarding shower schedules and issues with linen delivery, but no prior awareness of missed showers. Another resident, with diagnoses including chronic metabolic acidosis, muscle wasting, and a chronic skin ulcer, required supervision or assistance for personal hygiene and bathing. Observation showed this resident had long, yellow fingernails with a dark substance underneath, and the resident reported waiting for a bath and nail care. Documentation revealed missed or unverified showers and nail care, with staff acknowledging the resident could be difficult to bathe or provide nail care for, but also indicating that ADL care should have been provided prior to the resident leaving for a medical appointment if not refused. Record reviews and staff interviews confirmed that the facility's policy required providing necessary care for residents unable to perform ADLs to maintain proper grooming and hygiene. However, the facility did not ensure consistent delivery of showers, baths, and nail care for these dependent residents, as evidenced by missed care opportunities and incomplete documentation.
Failure to Change Gloves During Wound Care
Penalty
Summary
A deficiency was identified when the facility failed to ensure proper infection prevention and control practices during wound care for a resident. Specifically, the Wound Care Nurse did not change gloves between cleansing the wound and applying honey treatment and dressing, instead using the same gloves throughout the procedure. This was observed during a wound care session, where the nurse cleansed the wound, reused gauze on different areas, and then applied the prescribed honey treatment and dressing without changing gloves. The nurse acknowledged during an interview that not changing gloves could lead to infection, and the Director of Nursing confirmed that cross-contamination could occur if gloves are not changed at appropriate stages of wound care. The resident involved was a male with multiple diagnoses, including chronic pain, cellulitis, muscle wasting, cognitive impairment, and sepsis. He was totally dependent on staff for activities of daily living, always incontinent, and had a stage 3 pressure ulcer on his sacrum, with care plans and treatment orders in place for wound management. The facility's own dressing change policy required glove changes and hand hygiene at specific steps, which were not followed during the observed incident.
Failure to Provide Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with a history of COPD, dependence on supplemental oxygen, and other significant medical conditions, there was no current physician order for oxygen therapy despite the resident receiving continuous oxygen via nasal cannula. The care plan indicated a need for oxygen at 4L/min, and records showed ongoing use of oxygen since readmission, but the last documented physician order for oxygen had been discontinued months prior. The Director of Nursing confirmed that an order should have been in place and was not. For another resident with COPD exacerbation and congestive heart failure, the physician's order specified oxygen at 2 LPM via nasal cannula continuously. However, observations revealed that the oxygen concentrator was set at 3.5 LPM, exceeding the ordered flow rate. Multiple staff interviews confirmed that nurses were responsible for setting the oxygen flow rate according to physician orders, but the actual setting did not match the order. There was also confusion among staff regarding standing orders and titration parameters, but documentation and orders reviewed did not support the higher flow rate being used at the time of observation. The facility's own oxygen therapy policy required verification of physician orders for oxygen administration, including method of delivery and flow rate, and documentation of the resident's response. In both cases, the facility did not ensure that oxygen therapy was provided in accordance with physician orders and professional standards of practice, as required by the residents' care plans and the facility's policy.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of eight percent based on three errors out of thirty-five opportunities. These errors involved two residents and were identified through observation, interview, and record review. The first incident involved a resident with dementia, protein-calorie malnutrition, and constipation, who was dependent on staff for activities of daily living. The resident was administered Sennoside 8.6 mg instead of the ordered Sennoside 8.6 mg with Docusate 50 mg, and Multivitamins with minerals instead of the prescribed Multiple Vitamins without minerals. The nurse administering the medication stated that the correct medications were not available in the facility and that substitutions were made based on what was in stock, despite the differences in formulation. The medication supply room was found to have the correct Multiple Vitamins available, but the Sennoside with Docusate was on back order, and staff had been instructed to purchase it from an outside source. The second incident involved a resident with dementia who required assistance with activities of daily living. The medication aide applied a new Rivastigmine transdermal patch before removing the old one, contrary to the physician's order and facility policy, which required the old patch to be removed prior to applying a new one. The aide stated that she believed placing the new patch first would prevent contamination, and did not perceive a risk in having two patches on simultaneously if the old one was removed immediately after. The Director of Nursing confirmed that the correct procedure was to remove the old patch before applying the new one to avoid multiple patches being present at the same time. Facility policy reviews indicated that staff were required to confirm medication orders and follow specific procedures for oral and transdermal medication administration, including removing old patches before applying new ones. The errors observed were due to staff not following these established protocols, either by substituting medications without proper verification or by not adhering to the correct sequence for patch application.
Facility Fails to Maintain Safe and Comfortable Environment Due to Drafty Windows
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in one of the rooms reviewed. Specifically, the windows in the room occupied by two residents were not properly sealed, allowing cold air to enter. Observations revealed that the windows, made of plexiglass, were not secured to the frame, resulting in a strong draft of cool air. This issue was noted during a time when the outside temperature was 38 degrees Fahrenheit, and the residents expressed feeling cold in their room. The residents involved had significant medical conditions that could be exacerbated by the cold environment. One resident, a female with severe cognitive impairment, anemia, and reduced mobility, reported feeling constantly cold and was observed wearing multiple layers of clothing to stay warm. The other resident, a male with severe cognitive impairment, dementia, and other health issues, also reported feeling a draft and expressed a desire for a warmer room. Both residents had their beds positioned approximately four feet away from the drafty window. Interviews with staff, including an LVN, maintenance personnel, and the DON, revealed that complaints about the cold room had been made previously, but the window issue had not been addressed. Maintenance staff acknowledged the need for window repairs, and the facility's grievance records confirmed prior complaints about the room's temperature. Despite the provision of extra blankets, the facility did not take timely action to repair the windows, which compromised the residents' comfort and safety.
Deficiency in Meal Quality and Palatability
Penalty
Summary
The facility failed to ensure that the food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. During a survey, it was observed that the lunch meal served on October 15, 2024, consisting of Beef and Macaroni Casserole, Squash Medley, Peach Shortcake, and Coffee/Hot Tea, was not up to standard. The test tray revealed that the pasta was mushy and bland, the squash was chewy and bland, and the juice was diluted and watery. Interviews with residents confirmed that the meals were subpar, and the lunch served on that day was described as "nasty," leading to a lack of desire to eat it. The Assistant Dietary Manager acknowledged that the cook overcooked the pasta and mentioned the need for more staff and training to improve meal service. The Dietary Manager, who had been at the facility for two weeks, noted that the cook was new and inexperienced, which contributed to the poor quality of the meal. Although no direct complaints were received from residents, there was an unusual increase in requests for alternative meals, such as grilled cheese sandwiches, indicating dissatisfaction with the main meal. The Dietary Manager recognized the need for higher meal quality to ensure residents receive adequate nutrition.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their dietary services, as observed during a kitchen inspection. Specifically, drinks poured into individual cups were stored in the refrigerator without lids or covers and lacked labels. Additionally, a pitcher of chopped fruit was found without a date or label, and a bin of flour was not completely sealed, with gaps in its cover. These lapses in food storage practices could potentially expose residents to foodborne illnesses. During an interview, the Assistant Dietary Manager acknowledged the oversight, stating that the chopped fruit was intended for use as a garnish but was unsure of how long it had been stored in the fridge. She confirmed that all kitchen staff were responsible for ensuring that drinks and flour bins were properly sealed and covered to prevent contamination. A review of the facility's food storage policy, dated December 1, 2011, indicated that all opened and bulk items should be stored in tightly covered containers, labeled, and dated, which was not followed in this instance.
Inappropriate Incontinent Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a potential risk of urinary tract infections. During an observation, a CNA was seen cleaning a female resident from back to front during perineal care, which is against the facility's policy of cleaning from front to back to prevent infection. The CNA also failed to change gloves after cleaning the resident and before touching clean items, which could lead to cross-contamination. The resident involved was a female with multiple health conditions, including stroke, end-stage renal disease, heart failure, and dementia. She was frequently incontinent of bowel and bladder and required substantial assistance with personal hygiene. Her care plan included interventions to monitor and change her promptly to prevent skin breakdown and infection. Interviews with facility staff, including CNAs and LVNs, confirmed that the facility's policy was to cleanse from front to back to prevent infections such as E. coli. The staff acknowledged the importance of changing gloves and performing hand hygiene to prevent the spread of germs. The facility's policy and procedure documents also emphasized the need for proper perineal care to maintain hygiene and reduce infection risk.
Medication Error Due to Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 7% due to two errors out of 28 opportunities. One of the errors involved a resident who was administered medications for high blood pressure outside of the physician's prescribed parameters. The resident, who had a history of multiple health issues including heart failure and hypertension, was given Isosorbide and Carvedilol despite having a blood pressure reading below the threshold set by the physician's orders. The medication aide, MA B, administered the medications to the resident even though the blood pressure reading was 107/71, which was below the hold parameter of 110/60. MA B acknowledged the mistake after the surveyor left and reported it to the nurse and unit manager. The medication aide had recently received training and had been working at the facility for a month. The error was recognized as a potential risk for causing low blood pressure and related complications. Interviews with the nursing staff, including LVN D and LVN E, confirmed that the error was reported and the resident's blood pressure was rechecked. The Director of Nursing (DON) emphasized the responsibility of the nursing staff to follow physician orders and the risks associated with administering medications outside of prescribed parameters. The facility's policy required medications to be administered as prescribed, and the management team was responsible for ensuring compliance through periodic audits and reeducation.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of blood pressure medications. A medication aide, identified as MA B, administered Isosorbide and Carvedilol to a resident despite the resident's blood pressure and heart rate being outside the ordered parameters. The resident's blood pressure was recorded at 107/71, and the heart rate was 67 beats per minute, which did not meet the required parameters of holding the medication if the blood pressure was less than 110/60 and the heart rate was below 60. The resident involved was an elderly male with a history of multiple health issues, including heart failure, hypertension, and the presence of a cardiac pacemaker. His care plan indicated a risk for fluctuations in blood pressure and other complications, with specific interventions to monitor blood pressure and administer medications as ordered. Despite these precautions, the medication aide proceeded with administering the medications, later realizing the error and notifying the nursing staff. Interviews with the nursing staff, including LVN D and LVN E, confirmed that the medication was given outside the ordered parameters. The staff acknowledged the potential risks associated with this error, such as hypotension and dizziness, which could increase the risk of falls. The facility's policies and procedures emphasized the importance of administering medications as prescribed and highlighted the common types of medication errors, including administration errors due to staff shortages or miscommunication.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during incontinent care for a resident, leading to a potential risk of infection. The incident involved a resident who was frequently incontinent of bowel and bladder and required substantial assistance with personal hygiene. The resident had a history of multiple medical conditions, including stroke, end-stage renal disease, heart failure, and dementia, and was at risk for skin breakdown and infections. On the morning of October 16, 2024, CNA A provided incontinent care to the resident but did not change gloves or perform hand hygiene after cleaning the resident's perineal area and before touching clean items such as the brief and clothing. This lapse in protocol was observed during the care process, where CNA A used cleansing wipes to clean the resident but failed to remove the soiled gloves before handling clean items, thereby risking cross-contamination. Interviews with the CNA and other nursing staff, including LVNs and the DON, confirmed the breach in infection control practices. The staff acknowledged that gloves should be removed and hands washed after the dirty part of the procedure to prevent the spread of infection. The facility's policies on perineal care and hand hygiene were reviewed, which clearly outlined the need for proper glove removal and handwashing to maintain infection control standards.
Failure to Maintain Clean and Sanitary Environment in Secured Unit
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in a secured unit. Observations revealed that the hallway, dining room, and activity room floors were dirty, sticky, and covered with dust, dirt, debris, and spilled beverages. A resident was seen walking barefoot on the dirty hallway floor, indicating a lack of cleanliness and sanitation. The Housekeeping Supervisor and Maintenance Manager acknowledged the issues, with the former noting that floor techs were responsible for cleaning and should mop at least once a day, while the latter admitted to not verifying the floor techs' work adequately. Interviews with facility staff revealed a lack of proper oversight and accountability for floor cleanliness. The Housekeeping Supervisor mentioned that floor techs were moved to the maintenance department three months prior, and the Maintenance Manager admitted to only conducting visual checks when complaints arose. The Director of Nursing was aware of the sticky floors and mentioned plans to address the issue with new cleaning products and flooring. The facility's Operations Policies and Procedures manual emphasized the need for a safe and sanitary environment, which was not upheld in this instance.
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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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