Pleasanton North Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasanton, Texas.
- Location
- 404 W. Goodwin St, Pleasanton, Texas 78064
- CMS Provider Number
- 675502
- Inspections on file
- 28
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Pleasanton North Nursing And Rehabilitation during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment, extensive ADL needs, and high fall-risk scores had fall-prevention interventions in place that were not accurately reflected in their comprehensive person-centered care plans. One resident’s care plan listed hipsters, which she refused and did not wear, while omitting her actual interventions of a low bed, non-skid socks, and anti-skid floor tape. Another resident’s care plan for falls did not include his low bed, non-skid socks, anti-skid floor tape, or wheelchair anti-tip devices, despite staff and surveyor observations confirming these measures were in use. Staff reported relying on the Kardex, which is generated from the care plan, emphasizing the need for accurate documentation of fall-prevention interventions.
Staff did not follow the care plan for a resident with severe cognitive impairment and high fall risk, as the resident's bed was not kept in the lowest position as ordered and documented. Despite staff training and clear signage, the intervention was not implemented, contrary to facility policy and physician orders.
A resident with severe cognitive impairment and multiple diagnoses, who required assistance with eating, was referred to as a "feeder" by an LVN in the assisted dining room. This terminology was used despite facility policy requiring staff to treat residents with dignity and not label them by their care needs. The LVN later acknowledged the inappropriate language, and the DON confirmed it was unacceptable.
Two residents with moderate cognitive impairment and mobility issues were found without access to their call lights, despite care plans and facility policy requiring call lights to be within reach. A CNA was unaware of how the call lights became inaccessible, and both residents expressed concern about not being able to call for assistance.
A resident with diabetes and other chronic conditions had an MDS assessment that inaccurately recorded zero days of insulin administration, despite the MAR showing insulin was given on nearly all days in the review period. The MDS Coordinator relied on administration reports but failed to ensure the MDS accurately reflected the resident's actual insulin injections, resulting in incomplete and inaccurate clinical records.
The facility did not properly coordinate PASRR assessments for two residents with diagnoses of Major Depressive Disorder, as their PASRR Level I screenings failed to identify them as having a mental illness. Despite documented histories and care plans indicating mental health conditions, the required PASRR Level II assessments were not initiated. Staff interviews revealed a lack of awareness of these diagnoses, resulting in missed referrals for further evaluation.
A resident with hemiparesis, muscle weakness, and moderate cognitive impairment was found in bed without the required fall mat in place, despite care plan directives and facility policy. Staff interviews revealed the omission was due to an oversight during shift change and incomplete rounds, resulting in a failure to provide necessary accident prevention measures.
A resident with chronic pain and cognitive impairment did not have an accurate record of their controlled pain medication, Norco 5/325. The medication reconciliation log did not match the actual number of doses administered or the physical count in the blister pack, as confirmed by the MAR and staff interview. Facility policy required accurate and immediate documentation of controlled substances, but this was not followed, resulting in a discrepancy.
Surveyors found that a nurse medication cart contained an insulin pen without an opened date, and the medication room had expired flu collection swabs and specimen collection kits. The LVN and DON confirmed that these lapses could result in the use of expired medications or supplies, contrary to facility policy requiring proper labeling and removal of expired items.
A resident with dementia and unsteady gait experienced multiple falls, but the care plan was not revised in a timely manner to reflect these incidents or the interventions discussed by the care team. Although new measures were suggested and some were implemented, the care plan did not document all falls or interventions as required by facility policy, leading to gaps in care planning and communication among staff.
A resident with multiple mental health diagnoses and a history of falls experienced an unwitnessed fall from bed. The incident was reported internally but not reported to the State Survey Agency within the required timeframe, as staff misunderstood or did not follow the reporting requirements. No self-reported incident was found in the state portal, confirming the deficiency.
A resident with complex psychiatric and medical needs was transferred to a hospital for evaluation after exhibiting aggressive behavior. Despite being cleared for return, the facility did not allow the resident to come back, failed to document the basis for discharge, and did not provide the required discharge notice or summary, in violation of facility policy and regulatory requirements.
A resident with a cardiac pacemaker did not have a complete care plan, as required by facility policy. The care plan lacked the device's name, serial number, care instructions, and documentation of recent cardiac physician follow-up. Staff interviews and record reviews confirmed these omissions, and administrative staff could not provide the missing information.
A resident with a cardiac pacemaker did not have a care plan that included essential details such as the device’s serial number, care instructions, or documentation of recent cardiac physician appointments. The MAR also lacked information on pacemaker care, and staff could not provide a policy or evidence of recent follow-up, resulting in a failure to meet professional standards of practice.
A nurse held several doses of long-acting insulin for a resident with diabetes without a physician's order, despite the care plan and physician orders requiring daily administration. The nurse acted out of concern for hypoglycemia when the resident refused breakfast but did not document her reasoning, and there was no medical order to support holding the medication.
Meat products were stored above ready-to-eat foods in the kitchen freezer, contrary to facility policy and professional standards. The Dietary Manager, responsible for food storage, acknowledged the improper arrangement and cited difficulty lifting boxes and limited freezer space as contributing factors. The Dietician and Administrator confirmed the correct storage protocol, and facility policy requires raw animal products to be stored below other foods to prevent contamination.
A resident with significant physical impairments and dependence on staff experienced discomfort when the footrest of an electric bed remained elevated and the bed remote was not working. Although staff reported the issue through the facility's maintenance system, the bed was not repaired for several days, contrary to facility policy requiring immediate correction of such problems.
A resident's clinical record was not updated to reflect discharge from hospice services, leaving outdated physician orders and care plan entries indicating ongoing hospice involvement. Despite staff awareness of the resident's change in status, the record continued to direct staff to contact hospice and follow hospice-related orders, contrary to the resident's current care needs.
A resident with multiple chronic conditions and a venous ulcer was ordered to be on enhanced barrier precautions, but required signage indicating these precautions was not posted on the door as observed by surveyors. Staff interviews revealed a belief that the sign was present, but direct observation confirmed its absence, contrary to facility policy and training that require such signage to alert staff to use PPE during care.
The facility failed to update care plans for three residents after they experienced falls, despite interdisciplinary team reviews. A resident's care plan was not revised after a fall in the restroom, another resident's care plan was not updated after two falls resulting in a head injury, and a third resident's care plan was not revised after a fall onto a floor mat. The DON acknowledged the oversight, citing staffing issues as a barrier to consistent care plan updates.
A resident with dementia and other health issues experienced an unwitnessed fall resulting in a head laceration. The facility failed to conduct the required neurological assessments for 72 hours post-fall, as per protocol. Staff interviews revealed confusion and lack of accountability, with the DON acknowledging the oversight. The facility's procedure for such assessments was not followed, risking delayed interventions.
A resident with Alzheimer's and other conditions experienced an unwitnessed fall, but the facility failed to accurately document the required neurological assessments. Staff interviews revealed inconsistencies in the documentation process, with some records potentially misplaced. The facility's procedure for documenting neurological assessments was not followed, leading to incomplete medical records.
The facility failed to protect a resident from abuse and neglect when a CNA continued to provide care despite the resident becoming combative, resulting in multiple injuries. The facility did not suspend the CNA pending investigation, and the incident was initially treated as an injury of unknown origin rather than potential abuse or neglect.
The facility failed to implement written policies and procedures to prevent abuse, neglect, and exploitation. A resident with a history of dementia and neurodegenerative disorder sustained multiple injuries during peri-care with a CNA, who did not follow the care plan or call for help when the resident became combative. The incident was not reported immediately, and the CNA was not suspended pending investigation.
The facility failed to store, prepare, distribute, and serve food safely, with issues including expired food, improper freezer temperatures, unlabeled food, and an unclean ice maker. The Dietary Manager and Maintenance Supervisor confirmed these deficiencies, and the Administrator was unaware of these issues.
The facility failed to develop comprehensive care plans for three residents, omitting critical information such as code status and psychotropic medication use. This deficiency could lead to improper care and services being provided.
The facility failed to document psychiatric diagnoses and obtain informed consent for psychotropic medications for three residents. One resident received Quetiapine and Lorazepam without proper documentation, while two others received Mirtazapine for appetite stimulation without appropriate diagnoses. The DON acknowledged the deficiencies and lack of adherence to the facility's policy on psychotropic medication use.
The facility failed to report suspected abuse and injuries of unknown origin in a timely manner for two residents with severe cognitive impairments. One resident sustained multiple injuries during care, and another suffered a head laceration from an unwitnessed fall. Both incidents were not reported immediately, potentially contributing to further abuse and neglect.
The facility failed to ensure accurate PASARR screenings for two residents with mental health disorders. Both residents had documented diagnoses and medications for conditions like PTSD and depression, but their PASARR Level 1 Screenings did not reflect these mental illnesses. The MDS nurse did not take steps to correct the inaccuracies, contrary to the facility's policy on admission criteria.
The facility failed to ensure an LPN followed wound care policy by not dating and initialing dressings and did not complete treatment orders for a resident, marking them as done without actual assessment. The DON confirmed the importance of dating bandages and mentioned an action plan for skin audits.
A resident with chronic systolic heart failure and severely impaired cognition did not have her oxygen tubing changed weekly as ordered. The tubing, dated 4/15/24, had not been replaced according to the physician's schedule, and the DON confirmed that the night shift staff was responsible for this task.
A resident with type 2 diabetes and chronic kidney disease received insulin injections into the deltoid muscle instead of subcutaneous tissue, contrary to physician orders and facility policy. This improper administration was acknowledged by the LVN and confirmed as incorrect by the DON, highlighting a failure in following proper pharmaceutical procedures.
The facility failed to ensure proper labeling and storage of medications. The medication cart contained loose pills, debris, and dirty equipment. A bottle of polyethylene glycol was missing its expiration date. Interviews revealed a lack of assigned staff for cleaning the cart and checking expiration dates.
The facility failed to maintain an infection prevention and control program, as an LVN did not wash her hands properly before performing wound care on a resident. The LVN contaminated her hands by touching the paper towel dispenser after washing them. The DON confirmed the correct procedure, which was also outlined in the facility's hand hygiene policy.
The facility failed to maintain a dishwasher and vent hood in safe operating condition. The dishwasher did not meet the required temperatures for sanitization, and the vent hood inspection was overdue. Staff were unaware of these issues, and maintenance logs inaccurately reflected compliance.
The facility failed to provide a minimum of 80 square feet per resident in 20 of 46 rooms. The ADM had not reviewed room sizes but believed they were under a waiver. Record reviews confirmed non-compliance, and several rooms were dually occupied, potentially impacting residents' daily activities and quality of life.
A facility failed to protect two residents from abuse and neglect. One resident was physically restrained by an RN and an NA using a gait belt, and furniture was used to restrict movement. The same RN verbally abused two residents with derogatory language. Multiple CNAs witnessed the abuse but were initially hesitant to report it. The facility lacked consents or physician orders for restraints and did not have effective interventions for fall risks. The abuse continued until reported to state authorities, leading to an Immediate Jeopardy situation.
A resident with dementia and a history of falls was improperly restrained in a wheelchair using a gait belt by an RN and NA without a physician's order or consent. The restraint was not documented in the care plan, and several staff members witnessed the abuse but were initially hesitant to report it. The facility failed to ensure the resident was free from unauthorized restraints, leading to an Immediate Jeopardy situation.
A resident with dementia was improperly restrained using a gait belt by an RN, leading to an Immediate Jeopardy situation. The facility's policies did not clearly define restraint as abuse, causing confusion among staff about reporting procedures. Despite multiple staff witnessing the restraint, it was not reported immediately due to fear of retaliation and misunderstanding. The facility's failure to implement clear policies and procedures resulted in this deficiency.
A facility failed to properly store controlled medications, as a nurse pre-dispensed drugs like clonazepam, Lyrica, Ativan, and morphine into cups and stored them unsecured in a medication cart drawer. This practice was against facility policy, which requires controlled substances to be secured behind two locks. The DON was unaware of this practice, which was not aligned with the facility's guidelines.
A resident with dementia was restrained by staff using a gait belt without notifying the physician or family. The facility lacked documentation and communication regarding the incident, and the resident's care plan did not include restraints. Interviews revealed that key healthcare providers were unaware of the restraint, and the family was not informed.
A resident with progressive supranuclear ophthalmoplegia and other conditions did not receive necessary incontinent care when a nursing assistant failed to respond appropriately to the resident's call light. The resident's family, who had cameras in the room, reported the incident to the facility. The facility acknowledged the incident, noting that the NA was sidetracked and forgot to inform other staff members about the resident's need for care.
A nurse aide, NA H, worked full-time for two years in the facility without certification, failing to meet the regulatory requirement of certification within four months of hire. Despite completing a training program, NA H failed the certification test and did not retake it due to financial constraints. The DON was unaware of the certification requirement, and the facility's policy was not enforced, placing residents at risk.
Inaccurate Fall-Prevention Care Plans for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with accurate, measurable fall-prevention interventions for two residents identified as high fall risks. For the first resident, an older female with COPD, hypoxemia, dementia, adult failure to thrive, fatigue, and a history of falls, the quarterly MDS showed severely impaired cognition and extensive ADL assistance needs. Her fall risk assessment (FRA) score of 28 indicated high fall risk, with multiple recent falls, inability to stand independently, and loss of balance. Despite this, her comprehensive care plan listed hipsters as an intervention, even though she did not wear them, and did not include the actual fall-prevention measures in use: a low bed, non-skid socks, and anti-skid tape on the floor next to her bed. Surveyor observations confirmed that this resident was using a low bed, non-skid socks, and anti-skid tape, and was not wearing hipsters during multiple observations. Interviews with nursing and CNA staff who regularly cared for her consistently stated that she did not use hipsters, that hipsters had been tried but she refused them and removed them, and that her current fall-prevention measures were the low bed, non-skid socks, and anti-skid tape. Staff also explained that CNAs rely on the Kardex, which is generated from the care plan, to know and implement resident-specific interventions, underscoring the importance of care plan accuracy. The second resident, an older male with type 2 diabetes mellitus, difficulty walking, vascular dementia, insomnia, and a history of falls, also had severely impaired cognition and required extensive ADL assistance. His FRA score of 23 indicated high fall risk, with loss of balance while standing and need for direct assistance for mobility. His comprehensive care plan for falls did not include the fall-prevention interventions actually in place: anti-skid strips/tape on the floor, non-skid socks, anti-tip devices on his wheelchair, and a low bed. Surveyor observations and staff interviews confirmed that he had a low bed, non-skid socks, anti-skid tape on the floor, and anti-tip devices on his wheelchair, but these interventions were not reflected in his written care plan, contrary to facility policy requiring comprehensive person-centered care plans with measurable objectives and timeframes.
Failure to Implement Fall Prevention Interventions in Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and high fall risk. The resident, who had diagnoses including dementia and was dependent on staff for bed mobility and transfers, had a care plan and physician orders specifying the use of a low bed and fall precautions due to a history of falls and a subdural hematoma. Despite these documented interventions, the resident was observed lying in bed with the bed not in the lowest position, contrary to the care plan and posted signage in the room. Interviews with nursing staff and the Director of Nursing confirmed that all staff were responsible for ensuring the bed was kept in the lowest position for residents at risk for falls, and that training had been provided on this intervention. The staff acknowledged the bed was not in the correct position at the time of observation, and the resident was unable to adjust the bed independently. Facility policy required comprehensive care plans with measurable objectives and timeframes, but the failure to implement the specified fall prevention intervention was directly observed.
Resident Referred to as 'Feeder' in Assisted Dining Room
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, requiring assistance with activities of daily living including eating, was referred to as a "feeder" by an LVN in the assisted dining room. The resident had diagnoses of altered mental status, dysphagia, and unspecified dementia, and their care plan emphasized the importance of promoting dignity, conversing with the resident, and ensuring privacy during care. The facility's policy also required staff to treat residents with dignity and respect, specifically prohibiting labeling residents by their care needs. During an observation, the LVN was seen verifying diets and referred to the residents at the assisted dining table as "feeders." In a subsequent interview, the LVN acknowledged using a poor choice of words and stated that "assisted dining table" should have been used instead. The DON confirmed that referring to residents as "feeders" was unacceptable and not in line with facility expectations or policy.
Failure to Ensure Call Light Accessibility for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had access to their call lights, as required by their care plans and facility policy. For one resident with hemiparesis, muscle weakness, and moderate cognitive impairment, the call light was observed on the floor under the bed, and the resident was unaware of how it got there or what to do if assistance was needed. The resident's care plan specifically included an intervention to ensure the call light was within reach. For another resident with Parkinson's disease, bipolar disorder, anxiety disorder, and moderate cognitive impairment, the call light was found under the mattress, and the resident did not know its location, expressing concern about being able to call for help. A CNA assigned to both residents stated she did not know how the call lights became inaccessible but later clipped them to the bedspreads. She acknowledged that lack of access to the call light could lead to residents attempting to get up without assistance. The DON confirmed the importance of call light accessibility and stated that charge nurses monitor this during daily rounds. Facility policy requires staff to ensure call lights are within reach and secured as needed.
Inaccurate MDS Documentation of Insulin Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident, specifically regarding the documentation of insulin administration. For a female resident with multiple diagnoses including Type 2 Diabetes Mellitus, COPD, hypertension, hypothyroidism, and anxiety disorder, the quarterly MDS assessment did not accurately record the number of days insulin injections were received in the seven days prior to the assessment. The MDS assessment indicated zero days of insulin administration, despite the Medication Administration Record (MAR) showing that insulin was administered on 25 of the 26 days preceding the assessment. The MDS Coordinator reported that she relies on administration reports to determine the number of days insulin was given and inputs this information into the MDS system. However, the discrepancy between the MAR and the MDS assessment resulted in inaccurate documentation. The facility's policy requires qualified staff to conduct accurate assessments and documentation, but this was not followed in this instance, leading to incomplete and inaccurate clinical records for the resident.
Failure to Coordinate PASRR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program for residents with newly evident or possible severe mental illness. Specifically, two residents with diagnoses of Major Depressive Disorder (MDD) were not identified as having a mental illness on their PASRR Level I screenings, which would have required a PASRR Level II assessment. For one resident, records showed a history of MDD and psychiatric mood disorder, but the PASRR Level I screening indicated no evidence of mental illness. The resident confirmed a long-standing diagnosis of depressive disorder and intermittent medication use. For the second resident, documentation included diagnoses of MDD, anxiety disorder, and care plan interventions for depression, yet the PASRR Level I screening also indicated no evidence of mental illness. Interviews with facility staff revealed that the MDS Coordinator was responsible for referring and screening residents for PASRR re-evaluations but was unaware of the mental illness diagnoses for these two residents due to not having reviewed all active diagnoses. The Director of Nursing confirmed that the MDS Coordinator should have referred these residents for evaluation in accordance with facility policy. The facility's policy requires all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders per the PASRR process, but this was not followed for the two residents in question.
Failure to Ensure Fall Mat Use for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free from accident hazards and did not ensure the use of assistive devices as required for a resident with a history of falls and significant physical and cognitive impairments. The resident, a male with hemiparesis, muscle weakness, and moderate cognitive impairment, was assessed as unsteady on his feet and required assistance from two staff members. His care plan specifically included the use of fall mats when in bed to prevent injury from potential falls. During an observation, the resident was found in bed without the fall mat in place as required; instead, the mat was at the foot of the bed. The resident acknowledged the purpose of the fall mat and his tendency to forget his limitations. A CNA confirmed that the fall mat had not been placed due to an oversight during shift change and incomplete rounds. The DON stated that it was expected for all high-risk residents to have fall mats in place when in bed, in accordance with the facility's fall prevention policy.
Failure to Accurately Reconcile Controlled Medication Doses
Penalty
Summary
The facility failed to maintain an accurate system for recording the disposition of controlled drugs for one resident. Specifically, the medication reconciliation log for a Schedule II medication, Norco 5/325, did not accurately reflect the number of doses administered. On review, the Medication Administration Record (MAR) indicated that a morning dose had been given and 16 doses remained, but the controlled medication reconciliation log showed 17 doses available, while only 16 doses were physically present in the blister pack. This discrepancy was confirmed during an interview with the Medication Aide, who acknowledged the importance of immediately documenting the administration of controlled substances to prevent errors in the count. The resident involved was a female with chronic pain syndrome, anxiety disorder, hypertension, recurrent depressive disorders, hyperlipidemia, and pseudobulbar affect. She was moderately cognitively impaired and had been receiving both scheduled and as-needed pain medications. The facility's policies required that all controlled substances be recorded on the designated usage form and that the dose recorded on the usage form must match the MAR and other facility records. However, these procedures were not followed, resulting in an inaccurate reconciliation of the controlled medication.
Failure to Properly Label and Remove Expired Medications and Supplies
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored and labeled according to accepted professional principles. Specifically, during an inspection of a nurse medication cart, one out of five insulin pens was found without an opened date documented on the pen. When questioned, the LVN present acknowledged that without a date, it would be unclear how long the insulin pen had been in use, potentially leading to the use of expired medication. Additionally, during an observation of the medication room, expired supplies were found, including a package of flu collection swabs and a package of specimen collection kits. The DON confirmed that using expired supplies could result in improper functioning or inaccurate test results. Facility policy requires that drug containers be labeled with expiration dates and that expired items be reported to the nurse manager, but these procedures were not followed in the instances observed.
Failure to Timely Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with unsteadiness on feet and dementia, who experienced multiple falls. Despite the resident's severely impaired cognition and history of falls, the care plan was not revised in a timely manner to reflect four separate fall incidents. Documentation showed that new interventions were suggested by the interdisciplinary team (IDT) after each fall, such as the use of a hipster device, assessment for appropriate footwear, and cues for frequent rest breaks, but these interventions were not promptly or consistently incorporated into the resident's care plan. Record reviews indicated that the resident's care plan was only updated after a significant delay, and did not include all the falls that had occurred. Staff interviews revealed that while interventions were discussed in daily meetings and some were implemented in practice, the care plan itself was not updated after each fall as required by facility policy. The staff responsible for updating care plans, including the MDS nurse and the DON, acknowledged that care plans should be updated after every fall, but cited staffing limitations and lack of audits as reasons for the oversight. The facility's own policies required that care plans be reviewed and revised after each fall and after each comprehensive and quarterly MDS assessment. However, the care plan for this resident did not reflect the falls on four specific occasions, nor did it document all the interventions that were discussed and implemented by the care team. This failure to update the care plan in a timely and comprehensive manner could affect the delivery of care and services to the resident.
Failure to Timely Report Alleged Abuse Following Resident Fall
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, were reported to the State Survey Agency within the required 24-hour timeframe. Specifically, a male resident with schizoaffective disorder, major depressive disorder, and dementia, who was at risk for falls, experienced an unwitnessed fall from his bed. The incident was documented in the facility's records, and the RN notified the DON approximately 30 minutes after the fall. However, the event was not reported to the State Survey Agency as required by facility policy and state regulations. Interviews revealed that the DON believed allegations of abuse should be reported within two hours, while the Administrator did not report the fall because there were no injuries observed at the time. Upon review of the abuse guidelines, the Administrator acknowledged the reporting requirement but had not complied. A review of the Texas Unified Licensure Information Portal confirmed that no self-reported incidents regarding the alleged abuse were submitted for the resident on the date of the fall, indicating a failure to follow established reporting procedures.
Failure to Document and Notify Resident Discharge After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident was not transferred or discharged without adequate reason and proper documentation. A resident with diagnoses including dementia, paranoid schizophrenia, major depressive disorder, legal blindness, and anxiety was transferred to a hospital for a psychological evaluation following aggressive and combative behavior, including breaking a window and being combative with staff. Despite being cleared medically and psychiatrically at the hospital, the resident was not allowed to return to the facility. The facility did not document the basis for the resident's discharge, nor did it provide the required discharge summary or notice to the resident or their representative. The care plan for the resident was marked as cancelled and resolved shortly after the transfer, and there was no evidence in the records of a formal discharge process or communication of the discharge decision. Interviews with facility administration and the resident's family confirmed that the resident was not permitted to return due to behavioral concerns, despite the facility's awareness of these behaviors at the time of admission. Facility policy states that residents must be permitted to return following hospitalization unless specific criteria are met and that not permitting a resident to return constitutes a discharge. The lack of documentation and failure to follow the required discharge process could result in residents not having the opportunity to appeal the discharge, as noted in the findings.
Incomplete Care Plan for Resident with Cardiac Pacemaker
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a cardiac pacemaker. Record reviews showed that the care plan did not include essential information such as the pacemaker's name, serial number, or instructions on device care. Additionally, there was no documentation of a recent cardiac physician appointment to check the status of the pacemaker, and the Medication Administration Record (MAR) did not address pacemaker care. The care plan only mentioned avoiding electromagnetic interference and did not specify signs and symptoms to report to the physician immediately. There was also no evidence of a scheduled cardiac physician appointment in the resident's chart. During interviews, both the resident and a registered nurse confirmed the presence of a cardiac pacemaker, but administrative staff were unable to provide information regarding the device's details or recent follow-up care. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes to meet residents' medical, nursing, and psychosocial needs, but this was not followed in the case of the resident with a pacemaker.
Failure to Provide Comprehensive Care Plan for Cardiac Pacemaker
Penalty
Summary
The facility failed to ensure that a resident with a cardiac pacemaker received treatment and care in accordance with professional standards of practice and the resident’s comprehensive person-centered care plan. Record reviews showed that the resident’s diagnosis of a cardiac pacemaker was documented, but there was no physician order specifying the pacemaker’s serial number or instructions for device care. The Medication Administration Record (MAR) for the resident did not include care for the cardiac pacemaker, and the care plan lacked essential details such as the device’s name, serial number, and information about recent cardiac physician appointments to check the pacemaker’s status. The care plan only included instructions to report signs and symptoms to the physician immediately. Observations confirmed the presence of a cardiac pacemaker, and both the resident and nursing staff acknowledged its existence. However, during interviews, the Administrator and Director of Nursing were unable to provide information regarding a recent cardiac appointment or a policy specific to pacemaker care. The facility’s policy on comprehensive care plans requires that all services identified in the resident’s assessment be included to meet professional standards, but this was not followed for the resident with the pacemaker.
Failure to Administer Insulin as Ordered
Penalty
Summary
A deficiency occurred when a nurse failed to administer Insulin Glargine as prescribed to a male resident with vascular dementia, type 2 diabetes, and major depressive disorder. The resident's care plan required administration of medications as ordered, and physician orders specified a daily dose of Insulin Glargine. However, the medication administration record showed that several doses were held on specific dates, with documentation stating they were held per physician orders, despite no such orders being present in the resident's medical record for those months. The nurse responsible for holding the insulin doses stated she did so out of concern for potential hypoglycemia when the resident refused breakfast, but she did not document her reasoning in the progress notes. She later acknowledged that Insulin Glargine is a long-acting insulin and should not have been held without a physician's order. The Director of Nursing confirmed that licensed nurses are expected to follow physician orders regarding insulin administration.
Improper Storage of Meat Above Ready-to-Eat Foods in Kitchen Freezer
Penalty
Summary
Meat products, including bacon, diced turkey, honey hams, chicken, beef fritters, and chicken sausage, were observed stored above bread rolls, cookie dough, sweet potato fries, and individual pizzas in the facility kitchen freezer. This arrangement was noted during a kitchen observation, and the Dietary Manager confirmed responsibility for the storage. The Dietary Manager acknowledged that meat should be stored below other food items to prevent potential contamination from drips, especially if the freezer malfunctions and items begin to thaw. The Dietary Manager admitted to storing the food incorrectly due to difficulty lifting heavy boxes and limited freezer space. The Dietician stated that while there was an established order for food storage, specific training on freezer storage had not been provided to staff, but confirmed that meat is normally stored on the bottom. The Administrator also confirmed that facility policy requires meat to be stored at the lowest level in a drip pan to prevent contamination. Review of facility policy and in-service records showed that safe food storage practices were outlined, including the requirement for uncooked and raw animal products to be stored separately and below ready-to-eat foods.
Delay in Repair of Malfunctioning Bed Results in Resident Discomfort
Penalty
Summary
The facility failed to provide a safe, functional, and comfortable environment for a resident when the footrest on the electric bed remained in an elevated position and the bed remote was not working. The issue was first reported by a CNA through the facility's electronic work order system, but the bed was not repaired until several days later. During this period, the resident continued to use the malfunctioning bed, which was observed to be in an elevated position under the resident's lower legs and feet. The resident involved was an older male with significant medical conditions, including atherosclerotic heart disease, peripheral vascular disease, chronic venous hypertension with a leg ulcer, chronic kidney disease, and hemiplegia. He was dependent on staff for all activities of daily living, including bed mobility and transfers, and was incontinent of bowel and bladder. The resident's care plan indicated impaired physical functioning and dependence on staff for bed mobility. Multiple staff interviews confirmed that the malfunction was reported in the maintenance system, and the expectation was that essential resident equipment would be repaired the same day. However, the bed was not fixed until several days after the initial report. The facility's policy required immediate correction of such issues, but the delay resulted in the resident experiencing discomfort due to the malfunctioning bed.
Failure to Update Clinical Records After Hospice Discharge
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident who was discharged from hospice services. Despite the resident's discharge from hospice, the medical record, including physician orders and the care plan, continued to reflect active hospice services. This included orders to call hospice for certain conditions and documentation indicating the resident was still under hospice care, even after official discharge notices and cancellation forms were present in the record. The resident in question had multiple complex medical diagnoses, including atherosclerotic heart disease, peripheral vascular disease, chronic venous hypertension with ulcer, chronic kidney disease, and hemiplegia. The resident was dependent on staff for all activities of daily living and had a history of behavioral symptoms and incontinence. Interviews with staff, including LVNs, CNAs, the DON, and the MDS Coordinator, confirmed that the resident was no longer receiving hospice services, and that the clinical record should have been updated to reflect this change. However, the orders and care plan remained unchanged, inaccurately indicating ongoing hospice involvement. Staff interviews revealed that responsibility for updating the clinical record was shared among nursing staff, with the MDS Coordinator and nurse managers having access to make necessary changes. The DON and Administrator acknowledged that the inaccuracy in the clinical record could lead to errors in care and treatment, as staff might follow outdated orders. The facility's policy required maintaining complete and accurate electronic clinical records, but this was not followed in this instance, resulting in the deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Resident with Chronic Wound
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident who was ordered to be on enhanced barrier precautions due to chronic wounds. The resident, a male with multiple diagnoses including atherosclerotic heart disease, peripheral vascular disease, chronic venous hypertension with ulcer, chronic kidney disease, and hemiplegia, was dependent on staff for all activities of daily living and had a venous ulcer present. Physician orders and the care plan specified the need for enhanced barrier precautions, including the use of gowns and gloves during high-contact personal care activities. Despite these orders, observations on multiple occasions revealed that there was no enhanced barrier precaution sign on the resident's door, which is required to alert staff to the need for personal protective equipment (PPE) when providing care. Interviews with nursing staff and CNAs indicated that they believed the resident had a sign on the door and that such signage was standard practice for residents on enhanced barrier precautions. However, direct observation by surveyors confirmed the absence of the required signage during the survey period. The facility's policy and staff training materials indicated that signs should be posted on the door or wall outside the resident's room to indicate the type of precautions and PPE required. The lack of signage was confirmed by both the Director of Nursing and the Administrator, who acknowledged the importance of the sign for infection prevention and staff compliance. The deficiency was identified through record review, staff interviews, and direct observation.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for three residents were reviewed and revised by an interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. Resident #2's care plan was not updated to reflect a fall that occurred on 7/19/24. Despite the resident being found on the restroom floor and a subsequent IDT review, the care plan remained unchanged, which was acknowledged by the DON during an interview. Similarly, Resident #3 experienced falls on 8/17/24 and 8/18/24, but the care plan was not revised to include these incidents. The resident suffered a laceration and a head injury during these falls. Although an IDT review was conducted, no new interventions were initially suggested, and the care plan was not updated to reflect the falls, as confirmed by the DON. Resident #4's care plan was also not updated following a fall on 8/30/24. The resident was found on the floor mat with slight redness on the knee but no significant injuries. Despite a referral to therapy and an IDT review, the care plan did not reflect the fall. The DON admitted that due to staffing issues, she had not been able to update care plans consistently, which was corroborated by the AIT, who emphasized the importance of current care plans for resident safety.
Failure to Conduct Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that Resident #3 received appropriate treatment and care following an unwitnessed fall, as per the facility's protocol. The resident, who had a history of dementia, hypertension, unsteadiness on feet, dysphagia, cognitive communication deficit, repeated falls, and anxiety, experienced an unwitnessed fall resulting in a laceration above the right eye. Despite the facility's protocol requiring neurological assessments for 72 hours after such incidents, only four assessments were conducted, and the fall was not documented in the resident's care plan. Interviews with staff, including RN C and LVN A, revealed a lack of clarity and accountability regarding the completion of neurological assessments. RN C stated that the responsibility for completing these assessments was passed along during shift reports, but she did not know why they were not completed. LVN A also expressed uncertainty about the incomplete assessments, noting that agency staff were involved and might not have completed the required checks. The Director of Nursing (DON) acknowledged the importance of these assessments and admitted that they were not completed as per protocol. The facility's procedure for neurological assessments, revised in October 2010, outlines specific steps and frequencies for conducting these checks following an unwitnessed fall. However, the record review showed that the required assessments were not documented in Resident #3's electronic record, aside from the four noted in the progress notes. This failure to adhere to the protocol could result in residents not receiving timely interventions, as changes in condition might not be recognized promptly.
Incomplete Documentation of Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident following a fall, as required by professional standards. Specifically, the neurological assessments for the resident after an unwitnessed fall were not accurately documented. The resident, who had a history of Alzheimer's Disease, hemiplegia, type 2 diabetes, major depressive disorder, hypertension, and anxiety, experienced a fall on 8/30/24. However, the fall was not documented in the resident's care plan, and the facility was unable to locate the neurological records for the fall during the investigation. Interviews with staff revealed inconsistencies in the documentation process. RN D stated she completed a neurological assessment on 9/2/24 but documented it on paper, unaware that the facility had transitioned to electronic documentation. LVN A recalled completing neuro checks but could not remember the specific days and mentioned placing the documentation under the DON's door. The DON acknowledged the importance of completing neurological assessments to monitor for deviations from the resident's baseline but admitted that some records might have been misplaced. The facility's procedure required detailed documentation of neurological assessments, which was not adhered to in this case.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, the facility did not suspend CNA A pending an allegation of abuse or neglect when Resident #11 became combative during care. CNA A continued to provide care without calling for help, resulting in Resident #11 sustaining skin tears, bruising, and a left-hand fracture. The facility's inaction in suspending CNA A and not immediately addressing the incident led to the deficiency identified by the surveyors. Resident #11, a male with a neurodegenerative disorder with Lewy bodies and dementia, was admitted to the facility with a care plan that required two CNAs to assist him at all times due to his potential for combative behavior. On the day of the incident, CNA A was providing incontinent care to Resident #11, who became combative. Despite the resident's aggressive behavior, CNA A did not stop care or call for assistance, leading to multiple injuries on Resident #11, including skin tears and a fractured left hand. The facility's failure to follow its own protocols for handling combative residents and suspending staff pending investigation contributed to the deficiency. Interviews with the DON and Administrator revealed that the facility treated the incident as an injury of unknown origin rather than potential abuse or neglect. The DON and Administrator did not initially suspend CNA A, and the CNA continued to work at the facility. The facility's lack of immediate and appropriate response to the incident, including not suspending the involved staff member and not adequately investigating the injuries, resulted in the identified deficiency. The facility's policies and procedures for reporting and handling abuse allegations were not followed, leading to the deficiency noted in the report.
Removal Plan
- Patient care plan was updated to show Resident #1 has potential to demonstrate physical behaviors related to dementia. Resident #1 can become combative/agitated with care at times.
- IDT team reviewed and updated patient #1 Care plan to ensure patient had an appropriate focus, goal, and patient specific interventions specific to behaviors.
- 100% audit all patients with current behaviors had care plan updated appropriately to ensure appropriate focus goal and interventions are in place.
- DON/designee completed psychosocial assessment on resident #1, patient exhibited no signs or symptoms of psychosocial distress, nor any residual psychosocial or harm or distress was related to this.
- CNA A contract terminated.
- DON/Designee completed an audit of all residents through head-to-toe assessments and resident interviews conducted to validate all were free from signs and symptoms of abuse. No residents were identified to have any signs or symptoms of abuse at the completion of this audit.
- The Administrator/designee will provide education to all staff regarding identifying types of abuse.
- Administrator/Designee provided education to all staff on residents' right to be free from abuse and neglect.
- The Administrator/Designee will provide education to all staff regarding challenging behavior care and interventions for individuals experiencing dementia.
- All staff to include agency and contract staff, will be in-serviced upon assignment via phone and/or in person by the Director of Nursing/Designee before taking assignment in facility regarding resident with combative behaviors.
- The Clinical Corporate Resource provided education to the Director of Nursing and Administrator regarding the expectation that any staff member involved in allegations of abuse will be suspended immediately pending the outcome of further investigation.
- Administrator/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked.
- Ad hoc QAPl meeting held with IDT team and MD to review findings for immediate jeopardy.
- Administrator/Designee will conduct audits of all residents to validate that they are free of signs and symptoms of abuse in collaboration with nursing through interviews and examination.
- Administrator/Designee will implement interventions and education immediately if any concerns are identified with monitoring.
- Administrator/Designee will conduct staff interviews to determine knowledge of and competence related to: Types of Abuse, Challenging behavior care and interventions for individuals experiencing dementia.
- Monitoring will occur every shift to validate staff knowledge related to Abuse and dealing with residents with challenging behaviors.
- The Director of Nursing/Designee will track, on a printed staff roster, evaluation of staff interview outcomes and will document corrective actions taken if it is determined that knowledge deficits exist related to types of abuse, abuse/neglect reporting requirements and/or who the designated Abuse Coordinator is.
- Any trends or concerns will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate.
- Results of audits will be presented by the Administrator or designee at the monthly QAPI meeting with the IDT and Medical Director then monthly and as needed thereafter to identify trends and sustainability.
- If ongoing deficiencies or concerns are noted through these audits, resident interventions and staff education will be implemented immediately.
- The Administrator/designee will conduct monitoring of all cases of alleged/suspected/confirmed abuse to validate that proper, timely notifications have been made to resident representatives and providers through review of nursing documentation and that involved staff have been suspended timely pending further investigation. Any concerns identified will be corrected with prompt notifications, suspension and staff education/re-education as applicable.
- Monitoring will occur 7 days a week by Administrator/Designee Monitoring will not be discontinued until the facility completes three consecutive rounds of monthly monitoring that demonstrate sustained compliance as approved by the QAPI committee and medical director.
- Additional interventions, education and monitoring will be implemented, as needed, based on the recommendations of the QAPI committee for any negative trends identified to ensure sustainability.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation. Specifically, the facility did not follow its abuse policy and procedures when a resident obtained skin tears, bruising to hands, skin tears to forearms, and a left-hand fracture after peri-care with a CNA. The incident was not reported immediately, and the CNA involved was not suspended pending investigation, contrary to the facility's policy. The resident involved had a history of neurodegenerative disorder with Lewy bodies, dementia, and atherosclerotic heart disease. The care plan for the resident indicated that he could become combative with care and required two CNAs to assist him at all times. Despite this, the CNA provided care alone, and the resident sustained multiple injuries during the process. The CNA did not call for help or stop care when the resident became combative, leading to further injuries. The facility's DON and Administrator were aware of the incident but did not treat it as abuse or neglect. They did not suspend the CNA involved and continued to allow her to work. The facility also failed to report the incident immediately to the state as required. The lack of immediate action and proper reporting placed residents at risk of continued victimization and decreased quality of life.
Removal Plan
- Patient care plan was updated to show Resident #1 has potential to demonstrate physical behaviors related to dementia. Resident #1 can become combative/agitated with care at times.
- IDT team reviewed and updated patient #1 Care plan to ensure patient had an appropriate focus, goal, and patient specific interventions specific to behaviors.
- 100% audit all patients with current behaviors had care plan updated appropriately to ensure appropriate focus goal and interventions are in place.
- DON/designee completed psychosocial assessment on resident #1, patient exhibited no signs or symptoms of psychosocial distress, nor any residual psychosocial or harm or distress was related to this.
- CNA A contract terminated.
- DON/Designee completed an audit of all residents through head-to-toe assessments and resident interviews conducted to validate all were free from signs and symptoms of abuse. No residents were identified to have any signs or symptoms of abuse at the completion of this audit.
- The Administrator/designee will provide education to all staff regarding identifying types of abuse.
- Administrator/Designee provided education to all staff on residents' right to be free from abuse and neglect.
- The Administrator/Designee will provide education to all staff regarding challenging behavior care and interventions for individuals experiencing dementia.
- All staff to include agency and contract staff, will be in-serviced upon assignment via phone and/or in person by the Director of Nursing/Designee before taking assignment in facility regarding resident with combative behaviors.
- The Clinical Corporate Resource provided education to the Director of Nursing and Administrator regarding the expectation that any staff member involved in allegations of abuse will be suspended immediately pending the outcome of further investigation.
- Administrator/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked.
- Ad hoc QAPl meeting held with IDT team and MD to review findings for immediate jeopardy.
- Administrator/Designee will conduct audits of all residents to validate that they are free of signs and symptoms of abuse in collaboration with nursing through interviews and examination.
- Administrator/Designee will implement interventions and education immediately if any concerns are identified with monitoring.
- Administrator/Designee will conduct staff interviews to determine knowledge of and competence related to: Types of Abuse, Challenging behavior care and interventions for individuals experiencing dementia.
- Monitoring will occur every shift to validate staff knowledge related to Abuse and dealing with residents with challenging behaviors.
- The Director of Nursing/Designee will track, on a printed staff roster, evaluation of staff interview outcomes and will document corrective actions taken if it is determined that knowledge deficits exist related to types of abuse, abuse/neglect reporting requirements and/or who the designated Abuse Coordinator is.
- Any trends or concerns will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate.
- Results of audits will be presented by the Administrator or designee at the monthly QAPI meeting with the IDT and Medical Director then monthly and as needed thereafter to identify trends and sustainability.
- If ongoing deficiencies or concerns are noted through these audits, resident interventions and staff education will be implemented immediately.
- The Administrator/designee will conduct monitoring of all cases of alleged/suspected/confirmed abuse to validate that proper, timely notifications have been made to resident representatives and providers through review of nursing documentation and that involved staff have been suspended timely pending further investigation. Any concerns identified will be corrected with prompt notifications, suspension and staff education/re-education as applicable.
- Monitoring will occur 7 days a week by Administrator/Designee Monitoring will not be discontinued until the facility completes three consecutive rounds of monthly monitoring that demonstrate sustained compliance as approved by the QAPI committee and medical director.
- Additional interventions, education and monitoring will be implemented, as needed, based on the recommendations of the QAPI committee for any negative trends identified to ensure sustainability.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed expired food items, such as a unit of Hershey's cocoa mix, and a freezer with an internal temperature of 52 degrees containing unfrozen, thawed food. Additionally, dry storage bins containing rice and white flour were found open, and a bag of circular bread dough in the deep freezer was not labeled or dated. The Dietary Manager (DM) confirmed these findings and stated that the freezer had been inconsistently operating for several months, despite multiple verbal requests to maintenance for additional inspections. The DM also acknowledged that dry grain bins should be closed when not in use to prevent contamination. Further observations and interviews revealed that the ice maker contained white powdery buildup and dark brown and black sludge inside the unit. The DM was uncertain about the nature of the buildup but suggested it could be mold or rust. The Maintenance Supervisor (MS) stated that he had been working at the facility for several years and had last inspected the unit on a specified date. However, he admitted that he did not document the cleaning and only cleaned the outside of the unit or what his arm could reach inside. The MS suggested that the white powdery substance could be limescale buildup and acknowledged the potential risk of contamination. The Administrator (ADM) was unaware of the expired cocoa mix, the freezer's high temperature, the ice maker's cleanliness, or the unlabeled food in the kitchen. The ADM confirmed that the reach-in freezer unit had been non-operational since the last inspection and stated that it was her expectation for all food items to be labeled, dated, and stored at appropriate temperatures. Record reviews indicated that a service visit had been conducted, and the freezer was found to be overpacked, causing condensation. The facility's policy and FDA Food Code were also reviewed, highlighting the requirements for food storage and labeling.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for three residents, which included measurable objectives and time frames to meet their medical, nursing, and mental needs. Specifically, the care plans for Resident #23 and Resident #27 did not reflect their code status, and Resident #39's care plan did not include information about the use of psychotropic medications. This deficiency was identified through interviews and record reviews conducted by surveyors. Resident #23, a male with severe cognitive impairment and a diagnosis of unspecified dementia, had an active DNR order that was not reflected in his care plan. Similarly, Resident #27, a male with moderate cognitive impairment and a diagnosis of Parkinsonism, had an active full code order that was also missing from his care plan. The absence of these critical details in the care plans could lead to improper care and services being provided to these residents. Resident #39, a female with severe cognitive impairment and a diagnosis of chronic obstructive pulmonary disease, had multiple orders for psychotropic medications, including Haldol and ABH gel, which were not documented in her care plan. The facility's Director of Nursing (DON) was unaware of these omissions and acknowledged that high-risk medications should be included in care plans to monitor for changes in behavior and ensure proper administration. The lack of documentation for these medications in Resident #39's care plan could result in nursing staff being unfamiliar with the appropriate signs and symptoms to observe after administering the medications.
Failure to Document Psychiatric Diagnoses and Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for three residents reviewed for resident rights. Resident #12 did not have a documented psychiatric diagnosis for the psychotropic drug Quetiapine, which he was receiving daily. Additionally, Resident #12 had PRN orders for Lorazepam that exceeded the 14-day limit, with orders written for 90 days or with no end date. The facility also failed to obtain an updated and signed consent for the antipsychotic medication Quetiapine administered to Resident #12. Resident #14 was receiving Mirtazapine daily without a documented psychiatric diagnosis. The medication was indicated for appetite stimulation, but the resident did not have a diagnosis of loss of appetite, malnutrition, or related conditions. Similarly, Resident #20 was also receiving Mirtazapine daily without a documented psychiatric diagnosis. The medication was used for appetite stimulation, but the resident did not have a diagnosis to justify its use. The Director of Nursing (DON) acknowledged the deficiencies, stating that Resident #12's family refused to pay for psychiatric services, and the facility did not document the family's refusals. The DON also admitted to being unaware of the requirement for a physical signature on state consent forms and the need for a specific diagnosis for psychotropic medications. The facility's policy on psychotropic medication use was not followed, leading to residents receiving unnecessary medications without proper documentation and informed consent.
Failure to Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report to the state reporting agency (HHSC) in a timely manner possible neglect or abuse of a resident when he sustained injuries after care from a CNA. The resident, an elderly male with severe cognitive impairment and a history of combative behavior, sustained multiple skin tears and swelling to his hands and arms during care. Despite the injuries and the resident's inability to explain the cause, the facility did not report the incident immediately, treating it as an injury of unknown origin rather than potential abuse or neglect. The incident was only reported after an x-ray revealed a possible fracture days later. In another case, the facility failed to report an injury of unknown origin when a female resident with severe cognitive impairment suffered a laceration to her head. The resident was found on the floor with a bleeding laceration next to her wheelchair, and the staff assumed she fell while reaching for a drink. Despite the severity of the injury and the resident's inability to explain what happened, the facility did not report the incident to the state, concluding it was a fall due to the resident's history of falls and the lack of suspicious circumstances. Both incidents highlight the facility's failure to adhere to reporting requirements for suspected abuse, neglect, or injuries of unknown origin. The facility's inaction in promptly reporting these incidents could contribute to further abuse and neglect, as the proper authorities were not notified in a timely manner to investigate and address the potential issues.
Inaccurate PASARR Screenings for Residents with Mental Health Disorders
Penalty
Summary
The facility failed to ensure that two residents with mental health disorders were provided accurate Preadmission Screening and Resident Review (PASARR) screenings. Resident #11, a male with diagnoses including PTSD and Lewy body dementia, had a PASARR Level 1 Screening completed that did not indicate evidence of mental illness, despite multiple records showing he had PTSD and was on medications for depression and anxiety. Similarly, Resident #29, a male with diagnoses including anorexia, depression, PTSD, and insomnia, also had a PASARR Level 1 Screening that did not indicate evidence of mental illness, despite records showing he had PTSD, depression, and was on medications for these conditions. The MDS nurse responsible for these residents did not believe new PASARR assessments were needed and did not take steps to correct the inaccuracies in the screenings. The facility's policy on admission criteria requires all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASARR process. If a Level I screen indicates potential criteria for these conditions, a referral to the state PASARR representative for a Level II evaluation is required. The policy also states that the social services department should be notified for making referrals to the appropriate state-designated authority. However, in these cases, the facility did not follow its policy, resulting in inaccurate PASARR screenings for the two residents, potentially affecting their individualized care and specialized services.
Failure to Follow Wound Care Policy and Complete Treatment Orders
Penalty
Summary
The facility failed to ensure that LVN C followed facility policy while providing wound care to a resident by not dating and initialing the dressing. During an observation, LVN C provided wound care to a resident and did not date or initial the bandage. LVN C admitted that she normally does not date the wound dressing, although she acknowledged that she should. The DON confirmed that staff should date bandages to keep track of when they were last changed and suggested adding a label to the wound dressing with the date and initials. The facility also failed to ensure that LVN C completed treatment orders for another resident. LVN C documented that she completed wound care orders but did not actually perform them. The resident's records showed multiple orders to monitor various wounds, but LVN C marked these orders as completed without actually assessing the resident's skin. During an interview, LVN C admitted that she had not monitored the resident's wounds and had only marked it off in the electronic medical record. She also stated that she had not completed the skin assessment and did not want to document something she had not done. The DON stated that if staff did not complete wound assessments or wound orders, the wounds could become infected, and signs and symptoms of infection could be missed. The DON mentioned an action plan to perform skin audits where she would randomly pick residents and perform a skin assessment herself to verify the staff's documentation. The facility's policy on wound care requires staff to date and initial wound dressings, which was not followed in these instances.
Failure to Change Oxygen Tubing Weekly
Penalty
Summary
The facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice. Specifically, Resident #6's oxygen tubing was not changed weekly as ordered. The tubing was dated 4/15/24 and had not been replaced according to the schedule outlined in the physician's orders. This oversight was confirmed through record reviews and observations, which showed that the oxygen orders were not consistently followed on the specified dates in April and May 2024. Resident #6, a female with chronic systolic (congestive) heart failure and severely impaired cognition, was observed wearing a nasal cannula for oxygen therapy. Despite the physician's orders to change the oxygen tubing weekly, the tubing had not been replaced since 4/15/24. The Director of Nursing (DON) acknowledged that the night shift staff was responsible for changing the tubing and admitted that the staff should have been replacing the oxygen tubing as ordered to prevent complications.
Improper Insulin Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #26 by not following proper insulin administration procedures. Specifically, LVN C administered insulin into the resident's deltoid muscle instead of the subcutaneous tissue as ordered. This was observed during an insulin administration where LVN C injected 16 units of insulin into the deltoid muscle at a 90-degree angle, contrary to the facility's policy which requires insulin to be injected into subcutaneous tissue. LVN C admitted to not injecting the insulin into the fatty area of the back of the resident's arm and acknowledged that this could lead to improper absorption of the medication. Resident #26, a male with type 2 diabetes and chronic kidney disease, had a physician's order for insulin lispro to be administered subcutaneously before meals and at bedtime. The Director of Nursing (DON) confirmed that injecting insulin into the muscle was incorrect and could result in delayed absorption and formation of a knot in the muscle. The facility's policy on insulin administration clearly states that insulin should be delivered subcutaneously, and the failure to adhere to this policy was identified as a deficiency that could affect residents receiving medication, placing them at risk of adverse reactions or a decline in health.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with professional principles. During an observation, the medication cart was found to contain loose pills, shreds of paper, foil, broken pills, an earring, and other unknown debris. Additionally, a pill cutter and a pill [NAME] were found to be dirty with white powder and a brown sticky substance. A bottle of polyethylene glycol was missing part of its label, including the expiration date, and there was loose white powder in the top drawer where over-the-counter bottles were stored. The powder was also found on the outside of some bottles. Interviews with the LVN and DON revealed that no staff was assigned to clean the medication cart, and there was a lack of awareness regarding the loose pills and the condition of the cart. The LVN admitted to not checking for expiration dates on medications before administering them. The DON acknowledged that the cart should be kept clean and that any loose pills should be destroyed with an incident report filed if the pills' ownership was unknown. The facility's policy stated that drugs and biologicals should be stored in a safe, secure, and orderly manner, and any containers with missing or incorrect labels should be returned to the pharmacy for proper labeling.
Failure to Follow Proper Hand Hygiene Protocol
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections. Specifically, LVN C did not wash her hands properly prior to performing wound care on a resident. During an observation, LVN C washed her hands in the resident's restroom, but after rinsing her hands, she touched the paper towel dispenser with her bare hands to dispense a paper towel, thereby contaminating her hands again before proceeding with wound care. In an interview, LVN C acknowledged that she contaminated her hands by touching the paper towel dispenser after washing them and expressed uncertainty about the correct procedure. The DON confirmed that staff should dispense a paper towel before washing their hands, then use the paper towel to turn off the faucet after drying their hands. The facility's policy on hand hygiene, dated 8/2019, also supports this procedure. This failure to follow proper hand hygiene protocol could place residents at risk for infections.
Failure to Maintain Dishwasher and Vent Hood in Safe Operating Condition
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically concerning a dishwasher and a vent hood. The chemical dishwasher was observed to not meet the manufacturer's minimum requirements for rinsing and sanitization, with a maximum wash temperature of 112 degrees Fahrenheit and a maximum rinse temperature of 123 degrees Fahrenheit, both below the required 120 degrees Fahrenheit. The Dietary Manager (DM) was unaware of the dishwasher's failure to meet these temperatures and had not submitted a maintenance request. The Maintenance Supervisor (MS) also stated he had not received any work order requests related to the dishwasher and had not observed any concerns with its operation. The Vendor Technician confirmed that the dishwasher should reach 120 degrees Fahrenheit for sanitization but had not received any service requests from the facility regarding this issue. The facility's dishwasher temperature logs inaccurately reflected that the dishwasher met the required temperatures daily from June 1 to June 3, 2024. The facility's dishwashing policy mandates ceasing the use of the dishwasher if temperatures do not meet requirements, which was not followed in this case. The vent hood in the kitchen was also found to be deficient, with the last inspection conducted in February 2024 and the next scheduled for May 2024, which had not occurred. The DM confirmed that the vent hood had not been inspected since February 2024, and the MS was unaware that the contracted vendor had not visited in May 2024 as scheduled. The MS stated that the vent hood was inspected every three months and that the vendor usually came automatically without a request. The Administrator (ADM) was also unaware of the missed vent hood inspection and expected the MS to ensure timely inspections to prevent fire risks. The facility's failure to maintain the dishwasher and vent hood in safe operating condition could potentially expose residents to non-sanitized dishes and fire hazards. The ADM emphasized the importance of following the manufacturer's guidelines for the dishwasher and ensuring timely inspections of the vent hood. The facility's records and interviews with staff and the vendor technician highlighted lapses in communication and adherence to maintenance schedules, contributing to the identified deficiencies.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident in 20 of 46 resident rooms, specifically in rooms #1, #2, #3, #4, #5, #6, #7, #8, #11, #13, #15, #16, #17, #18, #19, #20, #21, #22, #23, and #25. This deficiency was identified through interviews and record reviews. The ADM admitted to not having reviewed the sizes of all rooms herself but believed they were under an existing size waiver. Record reviews of HHSC Form-3740 and HHSC Form-3763 confirmed that these rooms did not meet the required 80 square feet per resident. The facility's daily census indicated that several of these rooms were dually occupied, further exacerbating the issue. This failure could impact residents' ability to carry out activities of daily living and affect their quality of life.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically involving two residents. One resident was physically restrained by a registered nurse (RN) and a nursing assistant (NA) using a gait belt, which was wrapped around the resident's abdomen and secured to a wheelchair to prevent standing. This restraint was used from October 2023 to March 2024. Additionally, furniture was used to restrict the resident's movement, and the resident was subjected to emotional abuse by the RN. The resident had a history of dementia with behavioral disturbances, unsteadiness on feet, and generalized muscle weakness, requiring moderate assistance for mobility and being totally dependent on staff for activities of daily living. The same RN was also involved in verbal abuse towards two residents, using derogatory language and profanity. The incidents were reported by multiple CNAs who witnessed the RN's actions but were initially hesitant to report due to fear of retaliation. The facility's Director of Nursing (DON) was informed of the abuse, and the RN admitted to using the gait belt but denied using profanity. The facility did not have any consents or physician orders for the use of restraints on the resident, and the care plan did not include such interventions. The facility's failure to address these issues promptly led to the identification of an Immediate Jeopardy situation. The DON acknowledged the lack of effective interventions for the resident's fall risk and the absence of a reliable reporting system for abuse. Despite the RN's admission, the facility's response was delayed, and the abuse continued until it was reported to state authorities. The facility lacked surveillance cameras, which contributed to the difficulty in monitoring and verifying the abuse allegations.
Unauthorized Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by multiple instances where a registered nurse (RN) and a nursing assistant (NA) used a gait belt to tie the resident to a wheelchair. This action was taken without a physician's order or consent and was not documented in the resident's care plan. The resident, who had a history of dementia with behavioral disturbances and was unsteady on his feet, was restrained to prevent falls, according to the RN's admission. However, this restraint was not authorized and was considered a form of abuse. The deficiency was identified through observations, interviews, and record reviews. Several staff members, including CNAs and agency staff, witnessed the restraint but were initially hesitant to report it due to fear of retaliation. The Director of Nursing (DON) was informed of the situation by multiple staff members, and the RN involved admitted to using the gait belt as a restraint. Despite this, the RN continued to work at the facility for some time before being terminated. The facility did not have cameras to monitor the situation, and the exact duration and frequency of the restraint use were unclear. The resident involved was described as having a significant fall history and required moderate assistance for mobility. The care plan initially included a seat belt intervention, which was later removed. The resident's care plan did not include any orders for restraints, and there were no consents for physical restraints. The facility's failure to address the use of unauthorized restraints led to the identification of an Immediate Jeopardy situation, which was later removed, but the facility remained out of compliance due to the potential harm posed to residents.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation, specifically in the case of a resident who was restrained using a gait belt by a registered nurse (RN A). The facility's policy did not clearly define restraint as a form of abuse, leading to confusion among staff about what constitutes abuse and how to report it. This deficiency was identified as an Immediate Jeopardy (IJ) situation, indicating a serious threat to the health and safety of residents. The incident involved a resident with moderate dementia and behavioral disturbances, who was restrained in a wheelchair using a gait belt by RN A. The resident's care plan initially included a seat belt intervention, which was later removed, and there were no consents or physician orders for restraints. Multiple staff members, including CNAs and agency staff, witnessed or were aware of the restraint but did not report it immediately due to fear of retaliation or misunderstanding of reporting procedures. The Director of Nursing (DON) was informed of the situation but did not take immediate action to address the use of restraints. Interviews with staff revealed that RN A used the gait belt to prevent the resident from wandering and falling, despite the facility's policy of being restraint-free. The DON and other staff members were aware of the resident's wandering behavior and the family's request for restraints, but legal advice was against it. The facility's failure to clearly define and communicate policies regarding restraints and abuse led to inconsistent reporting and handling of the situation, resulting in the deficiency.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were stored properly in the medication cart, as observed with one of the two medication carts used by the licensed nurse. Controlled medications for several residents were not kept in their original packaging, were not appropriately labeled, and were not secured with two locks. Specifically, the nurse pre-dispensed DEA-controlled substances, including clonazepam, Lyrica, Ativan, and liquid morphine, into medication cups and stored them in the top left drawer of the medication cart, which was not secured behind two locks. The report details the medical conditions and medication orders for the residents involved. One resident had dementia with behavioral disturbance and was prescribed clonazepam. Another resident with Alzheimer's disease and anxiety disorder was prescribed Ativan and Lyrica. A third resident with dementia and heart failure was prescribed Lyrica, and a fourth resident with Parkinsonism and Alzheimer's disease was prescribed liquid morphine. The nurse was observed pre-dispensing these medications into cups labeled with the residents' names and storing them in the medication cart drawer, contrary to the facility's policy. During interviews, the nurse stated that she pre-dispensed medications to manage her time and ensure resident safety, although this practice was not in line with the facility's policy. The Director of Nursing (DON) was unaware of this practice and confirmed that it was not the facility's policy to pre-dispense medications. The DON also noted that medications should be secured behind two locks, and storing them in a regular drawer did not meet this requirement. The facility's policies on administering medications and handling controlled substances did not provide specific guidance on how controlled substances should be secured on the medication cart.
Failure to Notify Physician and Family of Restraint Incident
Penalty
Summary
The facility failed to immediately inform a resident's physician and representative when there was a change in the resident's condition. Specifically, the facility did not notify the physician or the resident's representative when it was discovered that a resident had been restrained by facility staff, including an RN, using a gait belt. This incident was confirmed as an allegation of abuse, yet there was no documentation of notification to the physician or the resident's family. The resident involved had a history of dementia with behavioral disturbances, unsteadiness on feet, and generalized muscle weakness. The resident required moderate assistance for mobility and was totally dependent on staff for activities of daily living. Despite these needs, there were no consents or physician orders for the use of physical restraints, and the resident's care plan did not include the use of restraints. Interviews with facility staff, including the DON, social worker, and medical director, revealed a lack of communication and documentation regarding the restraint incident. The DON admitted to terminating the RN involved but could not confirm if the physician or family had been notified. The medical director and other healthcare providers were unaware of the restraint incident, and the resident's family member was not informed about the use of a gait belt as a restraint.
Failure to Provide Incontinent Care
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living to a resident who was unable to perform them independently. The resident, who was diagnosed with progressive supranuclear ophthalmoplegia, depression, and aphasia, was cognitively intact but required moderate assistance with transfers and was frequently incontinent. The resident's care plan included having a call bell within reach and reminders to use it as needed. However, the facility did not ensure that the resident received incontinent care when requested, as evidenced by an incident where a nursing assistant (NA) did not respond appropriately to the resident's call light. The incident involved the NA turning off the resident's call light and stating that she would inform other staff members, but she did not follow through with this action. The resident's family, who had cameras in the room, observed the NA's failure to provide care and reported it to the facility. The family expressed concerns about the NA's history of not changing the resident and requested that the NA no longer care for the resident. The facility acknowledged the incident and noted that the NA was sidetracked and forgot to inform other staff members about the resident's need for care. Interviews with the Director of Nursing (DON) and the former DON revealed that the facility had not conducted any staff training on resident rights or call light response following the incident. The DON stated that staff should have honored their word and provided care even if it meant staying beyond their shift. The facility's policy on activities of daily living emphasized the importance of providing necessary services to maintain personal hygiene for residents unable to perform these tasks independently.
Failure to Ensure Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that a nurse aide, referred to as NA H, was certified within four months of hire as required by regulations. NA H was hired on October 11, 2022, and had been working full-time for two years without certification. Despite completing a training program from November 1, 2022, to December 31, 2022, NA H remained non-certified. The nurse aide had failed the certification test and had not retaken it due to financial constraints. The Director of Nursing (DON) was unaware of the regulatory requirement that nurse aides must be certified within four months of employment. During interviews, NA H admitted to failing the written portion of the certification test and expressed no intention to retake it due to financial issues. The DON confirmed that NA H had failed the clinical skills portion of the test and was responsible for paying for the retake. The facility's policy stated that nurse aides must complete a state-approved training program and competency evaluation within four months of employment, but this was not enforced. The lack of certification placed residents at risk of receiving care from an unproven individual.
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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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