Reunion Plaza Senior Care And Rehabilitation Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Texarkana, Texas.
- Location
- 1401 Hampton Rd, Texarkana, Texas 75503
- CMS Provider Number
- 675444
- Inspections on file
- 42
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 26 (2 serious)
Citation history
Health deficiencies cited at Reunion Plaza Senior Care And Rehabilitation Cente during CMS and state inspections, most recent first.
An agency LPN performed trach care on a resident with a trach, severe cognitive impairment, aphasia, dysphagia, and respiratory failure using contaminated sterile gloves and a contaminated suction catheter, then repeatedly tried to reinsert the inner cannula upside down without stabilizing the outer cannula until the surveyor intervened. The resident’s suction tubing was also found on the floor and later stored unbagged on top of clean supplies, and staff did not answer the call light when the LPN requested help during the procedure.
Late Administration of Routine Pain Medication: A resident with chronic pain and long-term opioid use did not receive scheduled oxycodone on time. The 7 a.m. dose was given at 9:41 a.m., the 11 a.m. dose at about 1:00 p.m., and the 3 p.m. dose at 4:10 p.m. The resident reported his pain increased quickly when doses were delayed and said he repeatedly asked the DON for his medication while waiting. The DON said she delayed the dose while trying to get meds back in time compliance and did not notify the MD; an LPN also said she delayed the dose for the same reason and did not notify the MD.
During a COVID-19 outbreak, the facility failed to ensure staff consistently followed its infection control policies for PPE use, hand hygiene, and isolation. Staff, including a CNA, an AC, an LVN, and the Dietary Manager, entered COVID-positive rooms and passed meal trays wearing only surgical or KN95 masks without required gowns, gloves, or eye protection, and in some cases moved between COVID-positive and non-COVID rooms without changing PPE or performing hand hygiene. PPE carts for multiple COVID-positive residents lacked N95 masks, gloves, and face shields/goggles, and one LVN performed a blood sugar check and then administered enteral medications without changing gloves or sanitizing hands. Residents involved had serious conditions such as COPD, cancer, cerebral palsy, stroke, fractures, neutropenia, and feeding tubes, and were on droplet/respiratory isolation per orders and care plans, but the ordered precautions and facility policies were not consistently implemented.
Insufficient nursing staff led to missed ADL care, bathing, incontinent care, repositioning, and delayed meds for multiple residents. A resident with CVA and hemiplegia remained soiled, unbathed for days, and reported missed meds, while other residents with high ADL needs had little or no documented bathing and were observed with body odor, urine saturation, and poor hygiene. CNAs and an LVN described impossible workloads, COVID isolation demands, and shifts with too few staff to complete required care, and the facility’s staffing levels were below its own assessment expectations.
Kitchen staff failed to follow food safety and infection control practices. An open, unlabeled bag of breadcrumbs was left unsecured in the dry pantry, an employee with facial hair worked in the kitchen without a mask or beard cover, and multiple staff members handled food, masks, and meal tickets without performing hand hygiene. Staff interviews confirmed these actions were inconsistent with facility policy and could contaminate food.
Residents were not included in their care plan conferences and the facility lacked documentation showing quarterly person-centered planning meetings occurred for several residents. Residents with diagnoses including CVA, diabetes, cerebral palsy, parkinsonism, and heart failure reported they had not been invited or had not participated in meetings where they could discuss meds, ADLs, food preferences, and other care needs. The SW stated the care plan conference form would need to be in the EHR for the meeting to be considered held, and the DON and Administrator acknowledged the responsibility for ensuring resident and IDT participation.
Resident council minutes and a confidential interview with 6 anonymous residents showed ongoing grievances about delayed call light response and showers not being provided as scheduled. Residents reported the issues would improve briefly and then return, with one resident waiting 3 hours and 42 minutes for a call light response, and they said staffing shortages contributed to late meds and missed showers. The Activity Director, DON, and Regional Administrator all acknowledged the concerns and stated they were responsible for addressing and monitoring them, but the DON reported there was no ongoing monitoring after staff education.
Missed baths and poor hygiene care were identified for multiple residents who depended on staff for ADLs. Several residents with conditions such as CVA, quadriplegia, COPD, heart failure, and cancer had little or no documented bathing during the review period, and some were observed with body odor, stained clothing, soiled linens, and unshaven facial hair. Residents and family members reported that showers were not consistently provided, while the DON acknowledged missed baths occurred amid staffing shortages and COVID-related absences.
DON Worked as Charge Nurse/CNA Despite Census Over 60: The DON stated she worked several floor shifts as a charge nurse and CNA when the facility was short staffed, even though she knew she was not supposed to work the floor in a building with more than 60 average residents. She also stated she was responsible for multiple nursing oversight systems and had not had time to keep up with them because she was working on the floor. Records showed an average daily census of 86 and staffing documentation listed the DON as charge nurse and CNA on the floor.
A resident with COPD and moderately impaired cognition had a physician order for Debrox ear drops for impacted cerumen, but the MAR showed the medication was not given for several scheduled doses. An LPN stated the drops had not been delivered from the pharmacy, while the DON stated the OTC medication was stocked in the med room and expected nursing staff to follow the MAR and physician orders.
Meals Served Cold, Bland, and Unappetizing: Multiple residents with intact cognition and varied diagnoses reported that meals were bland, cold, and poorly portioned. Observations confirmed cold baked fish, noodles, hushpuppies, and cobbler, and a resident who requested chopped food received chicken strips chopped into breadcrumb-like pieces with cold potatoes. Anonymous residents and staff also reported recurring complaints about cold food, small portions, and bland flavor.
A resident with Alzheimer’s disease had an unplanned discharge, and her legal representative submitted a written request, with a signed HIPAA authorization, for comprehensive medical and administrative records, including Medicaid-related correspondence, care plans, nursing and medication logs, and incident reports. Facility staff acknowledged receiving the request, but the Medical Records staff forwarded it to the Administrator and corporate attorney rather than processing it through the designated records request system, and there was no process to monitor the request after it was sent. The facility’s attorney later stated the request had been overlooked, resulting in the resident’s representative not receiving the requested records within required timeframes.
A resident with bowel and bladder incontinence, dependent for ADLs but cognitively intact, reported being cleaned only once per shift and sometimes going more than a full day without incontinent care, with staff placing blankets under her to catch urine. Surveyors observed two CNAs performing pericare with poor hand hygiene, including one CNA not washing hands before care and another washing only once, and proceeding without hand sanitizer. The resident’s brief was found completely saturated with a strong ammonia odor, and the resident stated she had not been changed since early morning and that her skin was sore. During care, the CNA wiped from the buttocks toward the vagina multiple times with the same wipe contaminated with BM, contrary to facility policy requiring wiping from vagina to anus with single-use strokes. The CNA later admitted she had not done pericare correctly and cited staffing issues, while the DON and Administrator stated expectations for timely, policy-compliant pericare to prevent infection.
A resident with quadriplegia, seizures, and HTN was dependent on staff for all ADLs and could not complete the BIMS interview. The family stated the resident was supposed to be out of bed daily for a few hours with shoes on, but repeated observations found him in bed with only socks on his feet. The CNA flow sheet and progress notes did not document refusals to get up or wear shoes, and staff interviews showed the resident had not been routinely offered or assisted out of bed despite the family’s stated preference.
Late Quarterly MDS Assessment: The facility failed to complete a quarterly MDS for a resident with osteomyelitis and dementia within the required timeframe. The MDS Coordinator acknowledged the assessment was late and had no reason for the delay, while the Regional Administrator confirmed the expectation that MDSs be completed within the RAI manual timeframes.
Baseline Care Plans were not completed within 48 hours for three newly admitted residents. One resident with a urinary catheter, stroke-related deficits, and other diagnoses had no catheter interventions on the plan; another resident with osteomyelitis, diabetes, a PICC, IV antibiotics, and a foot dressing had only diagnoses and allergies listed; and a third resident with a fracture, COPD, heart disease, depression, and a urinary catheter had no completed Baseline Care Plan. Admission MDS assessments were also not completed, and staff gave inconsistent accounts of who was responsible for the admission care plan process.
A resident with seizures and chronic intractable migraines reported ongoing headaches that were not relieved by his medications. An NP ordered a neurology referral for the migraines, but staff did not recall or implement the referral, and the resident had not yet seen a neurologist. The care plan did not reflect the resident’s chronic migraines, and the NP later noted she would follow up on the neurology appointment.
A resident with a G-tube, dysphagia, and severe cognitive impairment received scheduled lorazepam through the tube when an LVN pushed the medication and flushes with a syringe instead of administering by gravity. The LVN stated he routinely did this because the tube clogged frequently, and the DON confirmed this was not the proper method for G-tube medication administration. The facility’s enteral nutrition policy did not address medication administration through the feeding tube.
Medication administration errors and omissions were identified for two residents. An LPN prepared and gave one resident some crushed medications but omitted several scheduled vitamins that were documented as administered on the MAR, while an agency LVN gave another resident an incorrect bisacodyl form and did not administer the ordered esomeprazole magnesium even though both were signed out as given. Staff interviews showed confusion about who was responsible for certain medications and uncertainty with the MAR, dosage, and route.
A resident with CVA, right-sided hemiplegia, and multiple ulcers had a bed remote that only raised the head of the bed and would not lower it, adjust the foot section, or change bed height. Staff documented a maintenance request, but the remote remained broken for weeks, and the resident was repeatedly observed lying on his right side with his heels or feet against the footboard and unable to reposition himself. The wound NP and Maintenance Director both acknowledged the remote problem, and the DON and Administrator stated functioning bed remotes were important for resident safety and comfort.
Incomplete Comprehensive Care Plans: The facility failed to develop comprehensive person-centered care plans with measurable objectives and timeframes for four residents. The records showed missing care plan interventions for ADLs, falls, psychotropic and high-risk medications, diabetes, depression, seizure disorder, incontinence, hemiplegia, constipation, and other diagnoses despite MDS data documenting these needs. Interviews showed a CNA did not read care plans, the MDS Coordinator was responsible for completing them, and the DON stated major diagnoses, conditions, medications, and falls should be care planned.
Three residents experienced unsafe conditions during facility van transport, including falls due to improper wheelchair securement and unsafe driving by the van driver. One resident fell to the van floor when not secured with a seatbelt, another reported erratic driving, and a third was injured when the wheelchair tipped over after not being properly hooked in. The van driver failed to report incidents or follow emergency procedures, despite having received training on transport safety.
The facility did not provide or implement an infection prevention and control program, as required, with surveyors noting the absence of documentation or observed infection control practices.
Two residents with cognitive impairments eloped from a facility due to inadequate supervision and risk management. One resident, with severe cognitive impairment and Parkinson's, left unsupervised and was found at a local restaurant after crossing a busy road. Another resident, with dementia and a history of violent behavior, attempted to leave multiple times and fell outside the facility. Both incidents highlighted the facility's failure to provide adequate supervision and implement effective elopement prevention measures.
A facility failed to ensure that residents' drug regimens were free from unnecessary medications due to incorrect diagnoses being associated with their medication orders. One resident had diabetes medications linked to heart failure, while another had hypertension and pain medications associated with type 2 diabetes. A third resident's medications were incorrectly linked to acute kidney failure. This misalignment could lead to inappropriate treatment and monitoring.
A resident with hypertension and other conditions was administered antihypertensive medications despite blood pressure readings being below the prescribed parameters. The facility staff failed to notify the physician when the resident's blood pressure was outside the ordered range, leading to significant medication errors.
The facility failed to follow the posted menus and ensure proper portion sizes during two lunch meals, leading to potential nutritional inadequacies for residents. Substitutions were made without proper documentation, and staff interviews revealed dissatisfaction with portion sizes and menu adherence.
The facility failed to maintain food safety and sanitation standards, with unlabeled and undated food, carbon build-up on cookware, and improperly sealed containers. Food was served without temperature checks, and the Dietary Manager did not practice proper hand hygiene. The juice dispenser was also unclean. Staff interviews confirmed these practices did not align with facility policies.
The facility failed to provide palatable and properly heated meals, as reported by several residents and a family member. Meals were often cold, bland, and inconsistently cooked. Staff interviews revealed that the cook and Dietary Manager were responsible for ensuring food quality, but recent menu changes were not well-received. A test meal confirmed issues with food temperature and taste.
A facility failed to maintain effective infection control practices, as staff did not change gloves or perform hand hygiene during resident care. Two CNAs providing catheter care to a resident with multiple health issues did not follow proper glove use protocols. Similarly, a CNA assisting with incontinent care for a resident with Alzheimer's disease failed to change gloves and perform hand hygiene, risking cross-contamination. Interviews with facility staff confirmed the importance of hand hygiene, but observed practices did not align with facility policies.
A resident with severe cognitive impairment and high fall risk did not have her call light within reach, as observed over several days. Despite staff acknowledging the importance of call light accessibility, the resident's call light was often found hanging in the headboard or on the floor, contrary to the facility's policy.
The facility did not update the survey results book in the lobby, leaving the most recent state visit result outdated. The RNC and Administrator acknowledged the oversight, with the Administrator responsible for ensuring the book was current. This failure could prevent residents and families from being informed about past and current violation findings.
A facility failed to conduct a PASRR review for a resident with a new diagnosis of major depressive disorder. The resident did not receive the necessary evaluation and services due to the facility's oversight. Interviews revealed a lack of knowledge and coordination among staff regarding the PASRR process, and the facility's policy did not address updating PASRR Level 1 after a new diagnosis.
A resident with cerebral infarction and hemiplegia was not consistently assisted with transfers from bed to chair, despite her requests and care plan requirements. The facility's failure to provide necessary assistance led to the resident being confined to bed for a month, causing emotional distress and potential health risks. Staff interviews revealed a lack of adherence to the facility's ADL care policy.
A resident with severe pressure ulcers did not receive proper care due to incorrect settings on her pressure-relieving mattress, which was set for 250 pounds instead of her actual weight of 155 pounds. Observations confirmed the incorrect settings over several days, and interviews revealed confusion among staff about who was responsible for ensuring the correct settings. This oversight placed the resident at risk for further skin breakdown.
Two residents received inadequate perineal and catheter care, leading to potential risks of urinary tract infections. A resident with multiple diagnoses, including a UTI, was not properly cleaned during catheter care, and another resident with Alzheimer's was found with feces on her thigh, indicating improper incontinence care. Staff did not follow the facility's care policies, compromising infection control measures.
A resident with severe cognitive impairment and on enteral feeding experienced significant weight loss due to the facility's failure to follow the dietician's recommendations for Glucerna 1.5 and weekly weight monitoring. Staff were unaware of these recommendations, leading to a lack of action on the resident's nutritional needs.
The facility failed to ensure appropriate diagnoses and behavior monitoring for two residents prescribed psychotropic medications. One resident received Escitalopram without a proper diagnosis, while another lacked behavior monitoring for multiple psychotropic drugs. Staff interviews revealed lapses in documentation and adherence to facility policies on psychotropic drug use.
A resident's food preferences were not accommodated by the facility, despite clear communication of desired breakfast items. The resident did not receive requested boiled eggs on multiple occasions, and meal choices were not consistently obtained by the 2nd shift CNAs. The Dietary Manager and other staff acknowledged the issue, which was not aligned with the facility's policies on meal customization.
A resident with dementia and anxiety disorder was left exposed to the hallway by a CNA who failed to cover her and close the door after being asked to leave the room. The incident was confirmed by facility staff, highlighting a deficiency in maintaining the resident's dignity and privacy.
Two residents in an LTC facility experienced deficiencies in their care plans. A resident with Alzheimer's was observed without a required pillow in her wheelchair, risking comfort and skin integrity. Another resident with cerebral infarction had inadequate documentation of her meal intake, hindering nutritional monitoring. Staff interviews highlighted lapses in following care plan interventions and documentation responsibilities.
A facility failed to ensure accurate administration of Hydralazine for a resident with hypertension, as repeated identical blood pressure and pulse readings suggested checks were not performed. The resident's care plan required monitoring before each dose, but staff interviews confirmed the same readings could indicate falsification, risking potential harm.
The facility failed to update care plans for four residents following significant changes in their conditions, such as aggressive behavior and falls with injuries. Despite documentation of these incidents, care plans lacked necessary interventions, leaving staff without guidance. The MDS Coordinator and DON acknowledged the importance of timely updates, but the facility's policy was not followed.
A resident with complex medical conditions, including dialysis, was denied her request to be sent to the hospital by an agency nurse, LVN M, who deemed her medically stable. Despite the resident's self-reported symptoms of confusion and hallucinations, and her family's repeated calls, the nurse refused to call an ambulance, citing medical advice. The incident highlighted a failure to respect the resident's right to self-determination.
Two residents in a long-term care facility were subjected to abuse by CNAs. One resident's wheelchair was shaken during incontinent care, while another resident's wheelchair was forcefully pushed across a hallway. Both residents had severe cognitive impairments, and the incidents were witnessed by other staff members. The facility's abuse policy was not adhered to, leading to potential harm to the residents.
A resident with multiple health conditions was discharged from an LTC facility without proper discharge planning, resulting in a lack of necessary DME and medication instructions. The resident's early discharge was not communicated to home health or DME providers, leading to her readmission to the hospital. The facility's discharge policy was not followed, compromising the resident's safety at home.
A resident with severe cognitive impairment and high elopement risk exited a facility unsupervised and fell from his wheelchair, sustaining a head injury. Despite staff awareness of his risk and attempts to monitor him, the incident occurred during a busy meal service when supervision was insufficient. The facility's fall prevention measures were inadequate to prevent the accident.
A resident with sepsis and other conditions did not receive prescribed IV meropenem on time due to oversight in discharge orders and lack of follow-up by staff. The medication was delayed by three days, although the resident continued to receive vancomycin during dialysis. No acute issues were noted, and the missed doses were not deemed harmful by the NP.
Tracheostomy care performed with contamination, improper technique, and delayed response to call light
Penalty
Summary
Resident #5 had diagnoses including acute respiratory failure, epilepsy, hypertension, traumatic subdural hemorrhage, resistance to multiple antibiotics, aphasia, dysphagia, and severe cognitive impairment. She was dependent on staff for all ADLs and had a tracheostomy with orders for trach care every shift and suctioning as needed. The facility also had her on Enhanced Barrier Precautions. On 2/23/26, surveyors observed the resident’s suction equipment in an unsafe condition on two separate occasions. During one observation, the suction tubing had a long red rubber tube lying directly on the floor and it was not bagged. Later that day, the same tubing was observed unbagged in the top drawer of the nightstand on top of clean sealed supplies. The tubing was dated 2/12/26. On 2/25/26, LVN A, an agency nurse, was assigned to perform tracheostomy care even though she stated she had not done trach care in years and usually worked where a respiratory therapist managed trach care. During the procedure, she used non-sterile gloves, contaminated her sterile gloves and suction catheter, and suctioned the tracheostomy with the contaminated catheter. She also had difficulty reinserting the inner cannula, repeatedly attempted to force it in upside down without stabilizing the outer cannula, and caused the resident to cough forcefully with large amounts of secretions expelled from the tracheostomy. LVN A pushed the resident’s call light for help during the procedure, and staff did not respond until later. The surveyor intervened when LVN A continued to force the inner cannula in the wrong position, and the cannula was then inserted correctly.
Late Administration of Routine Pain Medication
Penalty
Summary
The facility failed to ensure effective pain management for Resident #21 by not administering routine oxycodone on time. Resident #21 was a cognitively intact male with diabetes type II, blindness in one eye, and chronic pain. His physician order was for oxycodone HCl 15 mg by mouth every 4 hours at 3 a.m., 7 a.m., 11 a.m., 3 p.m., 7 p.m., and 11 p.m. The care plan noted a history of verbally aggressive behavior related to medication timing, including becoming upset when the nurse was not present at the exact time pain medication was due, but no care plan was noted for chronic pain, opioid use, or opioid dependence. Record review showed the 7 a.m. oxycodone dose was administered at 9:41 a.m., the 11 a.m. dose at 1:03 p.m., and the 3 p.m. dose at 4:10 p.m. On interview, Resident #21 stated he had been dependent on opioids for over 20 years and that the medication had to be taken routinely to maintain acceptable pain relief. He reported that when a dose was missed or given late, his pain increased rapidly and was difficult to bring back under control. He stated that on the morning in question he was waiting for his pain medication, had approached the DON multiple times, and was told she would get to him when she could and later that she was going by room number. The DON stated she arrived late due to staffing shortage, told Resident #21 she would go down the hall and get all residents back in time compliance, and did not feel he was in enough pain to cause distress by waiting an extra hour for his medication. She also stated she did not notify the MD of the late administration. LVN SS stated she administered the late 11 a.m. dose around 1:00 p.m. and was trying to spread out the time and get the medication back in time compliance without giving too much medication, and she also did not notify the MD. The facility policy stated staff were to evaluate pain, use a pain scale to determine intensity, and provide pain medication as prescribed.
Failure to Implement PPE, Hand Hygiene, and Isolation Practices During COVID-19 Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during a COVID-19 outbreak, including failure to ensure staff consistently followed facility policies for PPE use, hand hygiene, and isolation practices. Surveyors observed multiple instances where staff entered COVID-positive residents’ rooms or provided services to them without the required PPE. A certified nursing assistant (CNA) passed meal trays on a COVID-positive hall without wearing a gown, gloves, N95 mask, or face shield/goggles, moving directly between COVID-positive and COVID-negative rooms. The Dietary Manager (DM) entered a room posted with droplet precautions multiple times wearing only a KN95 mask, delivering and removing meal trays and cups for COVID-positive residents, and did not consistently perform hand hygiene upon exiting the room. The report details that an Admission Coordinator (AC) delivered a meal tray to a COVID-positive resident while wearing only a surgical mask and no gown, gloves, or eye protection, despite droplet precaution signage on the door. After exiting the room, the AC handled cups and used the hallway ice chest and scoop without first sanitizing her hands, then returned the cups to nursing staff. Surveyors also observed that PPE supply carts for several COVID-positive residents lacked required items such as N95 masks, gloves, and face shields/goggles. During the same outbreak period, an LVN entered a COVID-positive resident’s room wearing only a KN95 mask and stated that a KN95 mask was appropriate and that face shields or goggles were optional, and later was observed in another COVID-positive resident’s room wearing only a surgical mask with no gown, gloves, or eye protection while assisting the resident. Additional deficiencies included improper glove use and hand hygiene during clinical care. An LVN checked a resident’s blood sugar and then administered enteral tube medications without changing gloves or performing hand hygiene in between tasks. Interviews with staff, including LVNs, the AC, the DM, the Infection Preventionist (ADON), the DON, and the Regional Administrator, confirmed inconsistent understanding and implementation of PPE requirements for COVID-positive rooms, confusion about the difference between N95 and KN95 masks, and uncertainty about who was responsible for stocking PPE carts. Facility policies reviewed by surveyors specified that N95 masks with goggles or face shields, gowns, and gloves were required for COVID isolation rooms, and that hand hygiene was required after removing gloves, after handling soiled items, and before handling food or medications. Despite these policies, observations and interviews showed that staff did not consistently adhere to these infection control requirements during the COVID-19 outbreak. The report also notes that several residents involved had significant medical conditions and were on isolation precautions for active infectious disease, including COVID-19. These residents included individuals with chronic obstructive pulmonary disease, Non-Hodgkin lymphoma, laryngeal cancer, cerebral palsy, prior COVID-19, neutropenia, fractures, and stroke-related hemiplegia/hemiparesis. Many had severe cognitive impairment as indicated by low BIMS scores, and some required extensive assistance with activities of daily living or had feeding tubes. Facility records, including care plans, MDS assessments, and physician orders, documented that these residents were COVID-positive and on droplet/respiratory isolation, with interventions specifying use of PPE and infection control practices. However, surveyor observations and staff interviews demonstrated that these ordered precautions and facility policies were not consistently implemented in practice.
Insufficient Nursing Staff Resulted in Missed ADL Care, Bathing, and Medication Delays
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs for ADL care, bathing, incontinent care, repositioning, and medication administration for multiple residents. The report states that the facility did not have enough staff available to provide resident ADL care routinely, and that this failure could put residents at risk of not receiving necessary care and supervision to maintain their highest practicable physical, mental, and psychosocial wellbeing. Resident #4 had diagnoses including CVA, right-sided hemiplegia, and vascular ulcers, and required partial assistance with bed mobility, personal hygiene, dressing, and transfer. He was observed repeatedly lying on his right side on his paralyzed arm and hand, with his feet hanging over the footboard and his remote bed controls not working. He stated he had not received a bath or shower in over 10 days, had been told staff did not have time to bathe him because of a COVID outbreak and short staffing, and had not received his medications over the weekend because the nurse said she would not make it to him in time. His room had a strong odor of body odor, his sheets were soiled and stained, and he remained in the same stained clothing over multiple observations. Other residents had similar missed care. Resident #2, who required substantial to maximal assistance with showers or baths, had only one bath documented for the month and said he had not had a bath in a week because staff said they did not have time. Resident #47, who required partial/moderate assistance with showering, had only one shower documented and reported missing scheduled showers. Resident #77, who was dependent for bathing and personal hygiene, had no baths documented for the month and was observed with ammonia and body odor. Resident #78, who was dependent for all ADLs, had no baths documented and family reported he was not being showered, was dirty, and needed oral care. Resident #90, who was dependent for ADLs and incontinent of bowel and bladder, had no baths documented, had very limited incontinent care documented on some shifts, and was observed with a saturated brief, urine leakage onto the sheets, and ammonia odor. Resident #104 reported he had not had a bath since admission and had only received a light wipe down. Staff interviews described widespread staffing shortages and inability to complete required care. CNAs reported having too many residents, including COVID-positive residents, and said they could not complete all baths, turning, cleaning, and charting. An LVN stated she gave only about 5 of 39 residents their medications on time during one shift and that there were 4 staff members caring for 88 residents for several hours. The Staffing Coordinator and DON stated CNA staffing was directed at 7 CNAs on day shift, 7 on evening shift, and 4 on night shift, but those numbers were not met on several days in February 2026. The facility assessment called for 9 CNAs on day shift and 9 on evening shift, while the detailed punch sheet showed staffing levels below that expectation on multiple dates. The facility also had 34 active COVID infections requiring isolation, and the Administrator stated there was no written staffing policy.
Kitchen Food Storage and Hand Hygiene Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its kitchen. During an initial tour on 2/23/26, surveyors observed a large white paper bag of tan/brown granulated particles identified by staff as breadcrumbs sitting open in a plastic trash bag on the bottom shelf of the dry pantry. The bag was not labeled or securely closed, and it had blue tape with a date written on it. The DM stated the bag should have been tied up or placed in a container and said leaving it open could allow bugs to get into it and make residents sick. Surveyors also observed multiple infection control and food handling issues involving kitchen staff. DA MM was seen preparing and pouring tea and water for meal trays while not wearing a mask and without a beard covering for his facial hair. Later, he was again observed walking through the kitchen and into the dining area without a mask or beard cover before returning and putting on a mask. The DM stated DA MM should have been wearing a mask in the kitchen and should have had a beard cover, and acknowledged that not doing so could make residents sick. On 2/24/26, [NAME] NN was observed preparing pureed foods and repeatedly pulling up her mask with her bare right hand while handling food and equipment. She then continued food preparation, including using a scoop in noodles and handling the blender bowl and blade with the same bare hand after adjusting her mask. During meal service, DA OO and DA PP handled meal tickets brought from a resident and from a staff member outside the kitchen and continued setting up meal trays without washing or sanitizing their hands. DA OO was also observed pulling up his mask twice while continuing to prepare trays without hand hygiene. Interviews with the DM, DA PP, [NAME] NN, the President of Nutrition, the DON, and the ADM confirmed that touching the face or mask and handling meal tickets from outside the kitchen required hand hygiene and that facial hair should be covered in the kitchen.
Residents Not Included in Care Plan Conferences
Penalty
Summary
The facility failed to ensure residents and/or their representatives were included in the development and implementation of their person-centered plans of care. Record review and interviews showed that for 5 of 18 residents reviewed, there was no documentation that the residents were involved in care plan conferences at the expected intervals, and the facility could not produce records showing that the comprehensive assessment and individualized care needs were reviewed with them. The missing documentation involved care plan conference records for multiple residents across several quarters, and the Social Worker stated that if the care plan conference form was not located in the EHR, the conference had not taken place. Resident #4 was admitted with CVA, right-sided hemiplegia, and vascular ulcers, had a BIMS of 15, and required partial assistance with several ADLs. The last recorded care plan conference was dated 03/26/2025, with no records found for later quarterly meetings. During interview, the resident stated he wanted to participate in care plan meetings, had not been invited since about a week after admission, and felt lost and left out of the process. Resident #21, admitted with diabetes type II, blindness to one eye, and chronic pain, also had a BIMS of 15 and was independent with ADLs, but the last recorded care plan conference was dated 11/20/2024 with no later conference records found. He stated care plan meetings were the time he could ask questions about medications, appointments, food preferences, and how CNAs treated residents. Resident #51, with cerebral palsy, dysphagia, and atrophic neurodermitis, had moderately impaired decision-making and required substantial assistance with ADLs; the last recorded care plan conference was dated 04/17/2025, with no later records found. Resident #81, with parkinsonism, orthopnea, and anemia, had a BIMS of 15 and required set-up assistance with ADLs; the last recorded care plan conference was also dated 04/17/2025, with no later records found, and the resident stated she had not received an invitation to a care plan meeting in about 1 year. Resident #90, with heart failure, obesity, and hypothyroidism, had a BIMS of 14 and required dependent assistance with ADLs; the last recorded care plan conference was dated 07/23/2025, with no later records found, and she stated she was upset that she was not included in planning her care and had concerns about the care she had been receiving.
Resident Council Grievances Not Promptly Resolved
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly on grievances and recommendations concerning resident care and life in the facility. Resident council meeting minutes documented repeated concerns about CNA response to call lights and showers not being given as scheduled across multiple meetings. The minutes reflected ongoing complaints that nurse aides were turning off call lights, not responding to resident needs, and that showers were not being provided as scheduled. In the confidential interview, 6 anonymous residents agreed their grievances about call light timing and showers were not resolved, and they reported that the issues would improve only for a few days before returning. During the confidential interview, the anonymous residents stated call lights were not answered timely, with one resident reporting a wait of 3 hours and 42 minutes for a call light to be answered. The residents also stated that at times only 2 CNAs were scheduled for the entire building and that all shifts were working short. They reported medications were given late and showers were not given as scheduled because of staffing concerns, and they felt ignored and neglected. The Activity Director stated she wrote resident council concerns up as grievances and brought them to morning department head meetings, with nursing concerns given to the DON. The DON stated she was aware of the ongoing grievances, had completed in-service education with staff, and followed up with residents who said the issues were resolved, but there was no ongoing monitoring after the education. The Regional Administrator stated department heads were responsible for addressing resident council grievances and following up at the next resident council meeting to ensure concerns were resolved.
Missed Baths and Poor Hygiene Care
Penalty
Summary
The facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for multiple residents who were dependent on staff for ADLs. Survey findings showed that several residents did not receive scheduled baths in February 2026, and two residents were also not groomed or shaved as needed. The report identified residents with a range of conditions including diabetes, CVA with hemiplegia, vascular ulcers, COPD with brain and lung cancer, quadriplegia, heart failure, obesity, hypothyroidism, and laryngeal cancer. Several of the residents had intact or moderately impaired cognition, while others had severe cognitive impairment or were unable to complete cognitive testing. Resident #2, who required substantial to maximal assistance with showers or baths, had documentation showing only one bath during the review period and told staff he had not had a bath in a week. Resident #4, who required substantial assistance with personal hygiene and had multiple wounds, was scheduled for showers three times weekly but received only one of eleven scheduled showers in February. He told surveyors he had gone more than 10 days without a bath, had asked for a shave, and was concerned about his body odor. Surveyors observed strong body odor, overgrown facial hair, stained clothing, and soiled sheets with food and fecal odor in his room over multiple days. Resident #47, who required partial to moderate assistance with showering, received only one shower during the review period and reported that he did not always get his scheduled showers. Resident #77, who was dependent for bathing and personal hygiene, had no documented baths in February and was observed with ammonia and body odor. Resident #78, who was dependent for all ADLs, had no baths documented and family members reported they had to come in to wash and bathe him, clean his mouth and face, and address crusting and drainage. Resident #90, who was dependent for ADLs and incontinent of bowel and bladder, had no documented baths and told staff she had not been bathed that month and felt embarrassed and raw from urine. Resident #104 had no baths documented after admission and stated he had only received a light wipe down and had not had a bath since admission. The DON stated baths were the responsibility of the CNAs, acknowledged missed baths had occurred because of staffing issues and COVID, and stated there was no excuse for the CNA not giving a bath related to time management.
DON Worked Floor Shifts Despite Census Over 60
Penalty
Summary
The facility failed to refrain from utilizing the DON as a charge nurse when the average daily occupancy was more than 60 residents. During observation and interview on 02/23/2026, the DON was changing linen on a bed in a resident room and stated she had worked several nights on the floor as a charge nurse and had also been a CNA when the facility was short staffed. She stated she knew she was not supposed to work the floor in a building with more than 60 average residents and said she would take the citation because she was not leaving residents with no care. She also stated she was responsible for monitoring the weight system, skin system, antibiotic stewardship system, and gradual dose reduction system, and that she had ADONs to assist her but the responsibilities were ultimately hers. The DON stated she had not had time to keep up with all the systems because she was working the floor and described duties that included checking nurses for clean oxygen equipment, verifying admission orders and admission assessments, ensuring residents were on the correct antibiotic, and confirming interventions were in place for weight loss and falls. She identified 6 shifts in January 2026 and 4 shifts in February 2026 when she worked on the floor. Record review showed an average daily census of 86 for January and February 2026, and February staffing records listed the DON as charge nurse on 02/22/2026 and as CNA on 400 hall on 02/23/2026. The Administrator stated the DON had worked the floor several shifts and that, because she was salaried, there was no way to track the exact days and hours she worked on the floor.
Failure to Administer Ordered Ear Drops
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals for one resident. Resident #1, a male admitted with COPD and a BIMS score of 12 indicating moderately impaired cognition, had a physician order entered on 02/24/2026 for Debrox 6.5% solution, 5 drops to both ears twice a day for 4 days for impacted cerumen. The resident’s care plan dated 10/17/2025 did not reflect the new Debrox order or acute hearing loss. The MAR for February 2026 showed the Debrox ear drops were not administered on 02/24/2026, 02/25/2026, or 02/26/2026. During interview, the LVN stated the order had been placed in the charting system but the ear drops had not been delivered from the pharmacy, so they had not been started yet. The DON stated Debrox was an OTC medication stocked in the medication room and expected nursing staff to communicate promptly when medications were running low or unavailable and to follow the MAR and physician orders. The Regional Administrator stated nursing management was responsible for monitoring to ensure medications were administered as ordered by the physician.
Meals Served Cold, Bland, and Unappetizing
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for multiple residents. The deficiency involved 7 of 19 residents reviewed, including residents with intact cognition and diagnoses such as mild protein-calorie malnutrition, diabetes, heart failure, depression, COPD, muscular dystrophy, and anxiety, as well as 7 anonymous residents who were interviewed about food quality. The report also noted a Resident Council Meeting Form stating that food was sometimes served cold on the halls. Resident interviews described repeated concerns that meals were bland, cold, and unappetizing. One resident with malnutrition and diabetes said the food did not taste good and was very bland. Another resident with diabetes, weakness, depression, and vitamin B deficiency said the food was not edible, was always very cold at the end of the hallway, and sometimes appeared burnt or clumped together. A resident with heart failure and diabetes said the food was always lukewarm and bland and that choices were limited. Another resident said the food was not good enough to feed to a stray dog, was always cold, portions were not enough, and family had to bring snacks. A resident with COPD and anxiety said the food was terrible, cold, and bland, and another resident with muscular dystrophy said the food was not seasoned and did not taste good. Observation and interview findings also showed problems with food temperature, texture, and appearance during meal service. One resident requested chopped chicken strips and potatoes, but the tray later served had chicken strips chopped so finely they looked like breadcrumbs; the resident said the tray was ice cold and the potatoes were hard. During a sampled lunch tray observation with surveyors and the Dietary Manager, baked fish, parmesan noodles, hushpuppies, and apple cobbler were all cold; the fish was bland, the noodles were chewy and had no flavor, and the cobbler was served cold and lacked crust. Anonymous residents reported that food was served cold most of the time, portions were small, and flavor was bland. Staff interviews reflected awareness of these complaints, including reports of cold food, watered-down coffee, bland meals, and undercooked potatoes, while the Administrator stated she expected kitchen staff to follow recipes and serve palatable food.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide timely access to personal and medical records to a resident’s legal representative after a valid request. The resident was an elderly female with Alzheimer’s disease who had been admitted with that diagnosis and later had an unplanned discharge with anticipation of return. Her attorney, acting as her legal representative, sent a written request for records, including all correspondence with the Texas Health and Human Services Commission related to the resident’s Medicaid nursing facility benefits for the prior two years, as well as the daily plan of care, nursing logs, medication logs, incident reports, and any emails, letters, and notes related to the resident. A HIPAA Authorization to Disclose Protected Health Information, signed by the resident’s legal representative, authorized the attorney’s office to receive any and all information concerning treatment or services rendered to the resident. Despite this, the attorney reported during interview that she had still not received the requested records months after the initial request, and she confirmed with Medical Records and the Administrator that the request had been received. Interviews and document review showed that the facility did not follow an effective process to ensure the request was fulfilled within regulatory timeframes. The Medical Records staff stated that attorney requests were sent to the corporate office and the facility’s attorney and were not handled at the facility level; she acknowledged awareness of the request and said it had been sent to the Administrator before he went on leave. The facility’s attorney/Chief Operating Officer later stated that the record request had been “overlooked and missed.” The Regional Administrator reported that the records request had been sent directly to the attorney rather than to the designated medical records request email and that there was no process in place to monitor the request after it was forwarded. The facility’s Release of Information Protocol indicated that legal and personal requests should be sent to a specific Medical Records Request email for review and presentation to the facility’s attorney, but the monitoring and follow-through steps were not carried out, resulting in the resident’s legal representative not receiving the requested records as required.
Failure to Provide Timely and Proper Incontinent Care and Pericare, Increasing UTI Risk
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate incontinent and perineal care to a female resident who was incontinent of bowel and bladder. The resident, an older adult with heart failure, obesity, and hypothyroidism, had an annual MDS showing a BIMS score of 14, indicating no cognitive impairment, and required dependent assistance with ADLs. ADL documentation for January and February 2026 showed very low recorded frequencies of incontinent care on day and evening shifts. The resident reported she was typically cleaned only once per shift and stated that on two occasions in the month she went more than an entire day without being cleaned. She also reported that CNAs placed blankets under her to catch urine and keep the sheets dry, and that she had contacted the Ombudsman after feeling the Social Worker and DON were not resolving her concerns. During an observed episode of perineal care, two CNAs entered the resident’s room to perform care. One CNA washed her hands only before starting care and not again until leaving the room, while the other did not wash hands before beginning care. One CNA stated she did not have hand sanitizer and that the facility did not provide it, and proceeded with care as usual. When the resident’s brief was removed, it was completely saturated, urine leaked onto the sheets, and there was a strong ammonia odor. The CNA stated it was the first time she had touched the resident that day, and the resident stated it was the first time she had been changed since around 2:00 a.m., reporting soreness of her thighs, buttocks, and vagina from being wet for a prolonged period. The CNA noted that blankets under the resident had likely been placed by night shift. During the same care episode, the CNA changed gloves without washing hands and continued incontinent care. She wiped from the top of the buttocks toward the vagina four times using the same wipe, with BM noted on the wipe when discarded, contrary to the facility’s perineal care policy, which directs wiping from vagina toward anus for females and discarding the washcloth after each stroke. In a subsequent interview, the CNA acknowledged she had not performed pericare correctly, citing lack of hand sanitizer and recognizing that wiping from back to front could cause infection. She also stated there was not enough staff to keep all residents clean and dry. The DON stated that hand hygiene and proper wiping technique were expected to prevent introducing bacteria to the urinary tract and that there were two CNAs on the hall with no reason for unreasonable delays in care, while also acknowledging a facility-wide problem with documentation. The Administrator stated she expected perineal care to be done “by the book,” timely and with infection-prevention techniques, and indicated she was unaware of the resident’s care problems because no grievance had been written despite the resident’s complaints.
Failure to Support Resident Choice for Daily Out-of-Bed Care and Footwear
Penalty
Summary
The facility failed to promote Resident #78’s self-determination by not consistently supporting the family’s stated preferences for the resident to be out of bed daily and to have shoes on during the day. Resident #78 was [AGE] years old, admitted with diagnoses including quadriplegia, seizures, and high blood pressure. The quarterly MDS indicated the resident was sometimes understood and sometimes understood others, could not complete the BIMS interview, and was dependent on staff for all ADLs. The care plan also identified the resident as dependent on staff for all ADLs and included assistance with daily care needs and daily living tasks. Record review showed no refusals documented on the CNA flow sheet for putting on or taking off socks and shoes or other appropriate footwear, and no refusals documented for transfers from bed to wheelchair. Interdisciplinary progress notes also did not show that the resident refused to get out of bed or wear shoes. During multiple observations, the resident was found in bed, including several times when only socks were on his feet and no shoes were present. A sign near the bed stated that the resident needed his shoes on from 2 to 4, and the family member said the resident was supposed to be out of bed with shoes on for a few hours each day. During interviews, the family member stated that care plan meetings had discussed the resident being out of bed every day for at least 2 hours and having shoes on his feet, and that the family wanted the facility to do what had been discussed. A CNA said she had never seen the resident up out of bed and had never offered to get him up. The DON stated she was aware the resident was supposed to be out of bed every day and have shoes on during the day, that he required a mechanical lift and two staff, and that she would expect staff to get him up daily and put him in his chair daily unless he refused. The Administrator also stated she would have expected the resident to be gotten up daily with shoes on if he was willing, and that refusals should have been documented.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete quarterly MDS assessments within the required 3-month timeframe for 1 of 19 residents reviewed, Resident #20. Resident #20 was a female admitted to the facility with diagnoses of osteomyelitis and dementia. Record review showed a quarterly MDS with an ARD of 01/22/2026 was completed on 02/26/2026, which was 35 days after the ARD date. Another quarterly MDS dated 10/25/2026 was completed within 14 days of the ARD date. During interview, the MDS Coordinator stated the quarterly MDS with the ARD of 01/22/2026 had not been completed yet at the time of the interview and acknowledged it was late, with no reason given for the delay. She stated she was responsible for ensuring MDS assessments were completed timely and that timely completion was important for regulatory compliance. The Regional Administrator stated she expected MDS assessments to be completed according to the required timeframes in the RAI manual and confirmed the MDS Coordinator was responsible for completing them. The facility policy stated quarterly assessments would be conducted not less often than once every 3 months, and the RAI Manual stated quarterly assessments must be completed no later than the ARD date plus 14 calendar days.
Baseline Care Plans Not Completed for New Admissions
Penalty
Summary
The facility failed to develop and implement a Baseline Care Plan within 48 hours of admission for 3 of 12 newly admitted residents. Resident #100 was admitted with diagnoses including hypertension, COPD, cerebral infarction, hemiplegia, visual disturbances, and muscle spasms. During observation, the resident had a urinary catheter hanging on the side of the bed, but the Baseline Care Plan did not include the catheter or related interventions. The resident’s admission MDS assessment had not been completed. Resident #101 was admitted with acute hematogenous osteomyelitis, diabetes, and polyneuropathy. The resident’s active orders included insulin, gabapentin, and two IV antibiotics. During observation, the resident was in bed with a PICC in the right upper extremity and reported receiving IV antibiotics for osteomyelitis of the foot after surgery to remove some toes, with a dressing present to the right foot. The Baseline Care Plan had been initiated but only listed diagnoses and allergies at the top of the form, with no other items or interventions marked, and it was not signed as completed. The admission MDS assessment had not been completed. Resident #103 was admitted with a fracture of the greater trochanter, major depressive disorder, heart disease, and COPD. Active orders included aspirin, wound treatment for a skin tear to the right lower extremity, hydrocodone, lorazepam, midodrine, glipizide, atorvastatin, and escitalopram. During observation, the resident was in bed and had a urinary catheter hanging on the side of the bed. The Baseline Care Plan was not completed within 48 hours of admission, and the admission MDS assessment had not been completed. Staff interviews showed differing understanding of who completed the Baseline Care Plan and what it should include, while the facility policy stated the Baseline Care Plan should be initiated and completed within 48 hours based on physician orders and nursing evaluation.
Failure to Implement Neurology Referral for Migraines
Penalty
Summary
The facility failed to ensure that Resident #91 received care in accordance with the nurse practitioner's order for a neurology referral for chronic migraines. Resident #91 was a male admitted with diagnoses of seizures and chronic migraine with aura, intractable. His quarterly MDS reflected clear speech, ability to understand and be understood, and a BIMS score of 12 indicating moderately impaired cognition. His comprehensive care plan dated 10/31/2025 did not reflect his chronic migraines. The nurse practitioner's note dated 12/10/2025 documented that Resident #91 reported ongoing migraines and that the medications he was taking were not helping; a neurology referral was ordered at that time. A later note dated 02/03/2026 stated, "Will follow up with staff on neurology appointment." During interview, Resident #91 said he had recurrent migraines, the medications were not helping, and he had not yet seen a neurologist even though he was told a referral would be sent. Staff interviews reflected that the referral order was not recalled or implemented, and the nurse practitioner stated the facility was supposed to have placed the referral.
Improper G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided for a resident who received nutrition and medications through a gastrostomy tube. Resident #31 was admitted with diagnoses including gastrointestinal hemorrhage, dysphagia, and gastrostomy status. Her record showed severe cognitive impairment with a BIMS score of 03, and her care plan identified the feeding tube as necessary for nutritional needs due to dysphagia, with interventions to monitor for dislodgment, blockage, leakage, and signs of infection, and to observe tube placement before each feeding. During medication administration, LVN O used a 60 mL feeding tube syringe to push the resident’s scheduled lorazepam into the gastrostomy tube and also pushed the flushes before and after the medication. He stated he normally pushed the resident’s flushes and medications because the tube stopped up frequently, and he acknowledged the medication probably should have been given by gravity. The DON stated pushing medications or flushes through a gastrostomy tube was not the proper way to administer medications and that they should have been given via gravity. The facility’s enteral nutrition policy addressed safe enteral nutrition therapy but did not address medication administration through the feeding tube.
Medication administration errors and omissions
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent, with 7 errors out of 32 opportunities for a 21.88 percent medication error rate for 2 of 7 residents reviewed for medication error. The report identified that Resident #20 did not receive scheduled Vitamin C, B-12 methyl, magnesium oxide, multivitamin with minerals, and Vitamin D3 during a medication pass on 02/24/2026, even though those medications were listed on the active orders report and were signed out on the MAR as administered. During the observation, LVN O prepared four pills, crushed them, mixed them with applesauce, and administered them to Resident #20, but did not include the resident’s scheduled vitamin C, B-12 methyl, magnesium oxide, multivitamin with minerals, and Vitamin D3. In interview, LVN O stated he was only responsible for certain medications that required blood pressure, assessment, or monitoring, and said he was not responsible for administering the resident’s vitamins. He stated MA P gave Resident #20 her vitamins. MA P later stated LVN O was responsible for giving Resident #20 all her medications and that she had not given the resident medications for a while. The report also identified that Resident #34 did not receive esomeprazole magnesium and did not receive bisacodyl in the ordered suppository form during a medication pass on 02/25/2026. LVN U prepared 8 tablets for administration, including one bisacodyl 5 mg tablet, but did not include or administer the ordered esomeprazole magnesium. The active orders showed esomeprazole magnesium 20 mg as a capsule and bisacodyl 10 mg as a suppository, while the MAR reflected both medications as signed out as given. LVN U stated she was new to the facility, worked with agency, did not give the esomeprazole because it needed to be reordered, and overlooked the bisacodyl dosage amount and route or form because she was nervous and new to the charting system and facility.
Nonfunctioning Bed Remote Left Resident Unable to Adjust Position
Penalty
Summary
The facility failed to maintain a resident’s bed remote in safe operating condition. Resident #4, a male admitted with CVA, right-sided hemiplegia, and vascular ulcers, had a quarterly MDS showing a BIMS score of 15 and required partial assistance with bed mobility, personal hygiene, dressing, and transfers. His care plan identified a venous stasis ulcer on the right lateral ankle, a right medial calf ulcer, and a non-pressure ulcer to the right buttock. Record review showed a maintenance request dated 12/09/2025 stating the bed remote in Resident #4’s room was not working consistently, but the Maintenance Director marked it as checked and completed. During multiple observations, Resident #4 stated the remote had a short for over 2 months and would only raise the head of the bed, but would not lower the head, raise or lower the foot of the bed, or adjust bed height. He was observed repeatedly positioned on his right side, lying on his paralyzed right arm and hand, with his feet or heels resting on the footboard, and he stated he could not reposition himself because the remote did not work. Resident #4 also stated he had spoken with maintenance several times about replacing the remote, but it had not happened. The wound NP stated he was concerned about the resident’s heels resting on the footboard and that the bed remote had not worked in the last 6 to 8 weeks. The Maintenance Director later stated he had not been aware the remote was not functioning properly, then recalled the work order and said he ordered a new remote that had not arrived yet. The DON and Administrator stated functioning bed remotes were important and that maintenance was responsible for checking equipment and completing work orders.
Incomplete Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 4 of 18 residents reviewed. Record review showed that Resident #4, a male admitted with CVA, right-sided hemiplegia, and vascular ulcers, had a quarterly MDS indicating a BIMS of 15, no behaviors, no refusal of care, and need for partial assistance with bed mobility, personal hygiene, dressing, and transfers, yet his care plan did not include plans for ADLs, falls, psychotropic medication, or insulin use. Resident #21, a male admitted with diabetes type II, blindness to one eye, and chronic pain, had a quarterly MDS showing a BIMS of 15, no behaviors, no refusal of care, independence with ADLs, and use of multiple high-risk medications including antianxiety, antidepressant, hypnotic, diuretic, opioid, hypoglycemic, and anticonvulsant drugs. His care plan dated 10/01/2025 did not include care plans for antianxiety medication, antidepressant, hypnotic, diuretic, hypoglycemic, anticonvulsant, or opioid usage. Resident #23, a female admitted with diabetes type II, depression, and peripheral vascular disease, had a quarterly MDS showing a BIMS of 15, partial assistance with ADLs, depression, seizure disorder, diabetes, antidepressant use, opioid use, and multiple falls with no injury, but her care plan dated 10/27/2025 did not include depression, antidepressant use, seizure disorder, opioid use, diabetes, or multiple falls. Resident #34, a male admitted with CVA, right-sided hemiplegia, and seizure disorder, had a quarterly MDS showing a BIMS of 06, hemiplegia, constipation, traumatic brain injury, depression, anxiety, seizure disorder, bowel and bladder incontinence, and daily antidepressant and diuretic use. His care plan dated 11/02/2025 did not include hemiplegia, constipation, traumatic brain injury, depression, anxiety, seizure disorder, incontinence, or antidepressant and diuretic use. During interviews, a CNA stated she did not read care plans because she was not sure how, the MDS Coordinator stated she was responsible for completing all comprehensive and acute care plans and that no one in the facility reviewed them for completion, the DON stated major diagnoses, conditions, medications, and falls should be care planned, and the Administrator stated she expected staff to follow the interventions decided on by the MDS coordinator and IDT.
Failure to Prevent Accident Hazards During Resident Transportation
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents during transportation. Three residents experienced incidents related to unsafe transport practices. One resident, who was dependent on staff for transfers and used a wheelchair, reported falling to the floor of the facility van when the driver swerved to avoid another vehicle. The resident was not secured with a seatbelt, slid out of the wheelchair, and was assisted by dialysis clinic staff. The incident was not reported by the van driver or the resident to facility staff, and there was no documentation of the fall in the facility's records. Another resident complained about the van driver's unsafe and inattentive driving, stating that the driver was more focused on his drink than on the road. The administrator received this complaint and counseled the driver, but the unsafe driving behavior continued. A third resident, who was also dependent on staff for transfers and used a wheelchair, was not properly secured in the van. The van driver failed to attach one of the wheelchair hooks, causing the wheelchair to tip backward during transport. The resident sustained a skin tear and a bruise, complained of a headache, and was later sent to the emergency room for evaluation. The van driver did not notify facility staff or call emergency services at the time of the incident, instead continuing with the transport as planned. The van driver involved in these incidents had received periodic training on transportation safety and facility policies, which included instructions on securing residents and responding to emergencies. Despite this, the driver failed to follow established procedures, such as securing wheelchairs and reporting incidents. The facility's records indicate that the driver did not report falls or injuries as required, and interviews with staff and residents confirmed lapses in communication and adherence to safety protocols.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. Surveyors identified that the required program was either not established or not effectively carried out, as evidenced by the lack of documentation or observation of infection control practices. There were no specific details provided regarding individual residents, staff actions, or particular infection control breaches, but the absence of a program itself constituted the deficiency.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, leading to their elopement. Resident #289, a male with severe cognitive impairment due to neurocognitive disorder with Lewy bodies and Parkinson's disease, eloped from the facility. Despite being a moderate elopement risk, he was allowed to sit outside unsupervised, which facilitated his departure. He was later found at a local restaurant, having crossed a busy road, and sustained minor injuries from a fall. The resident expressed confusion about his ability to leave the facility and demonstrated impulsive behavior, which was not adequately managed by the facility. Resident #290, a male with dementia and a history of violent behavior, was identified as a high elopement risk. He attempted to leave the facility multiple times, believing he was meeting a deceased family member. On one occasion, he fell outside the facility, sustaining minor injuries. Despite being on 15-minute checks, the facility's measures were insufficient to prevent his attempts to leave. Staff struggled to redirect him, and his persistent attempts to elope highlighted the inadequacy of the facility's supervision and risk management strategies. The facility's failure to provide adequate supervision and implement effective elopement prevention measures placed both residents at risk of harm. The incidents revealed lapses in monitoring and assessing residents' elopement risks, as well as a lack of timely intervention to prevent their unsupervised departure from the facility. These deficiencies were identified as posing an immediate jeopardy to resident safety, necessitating corrective actions to address the identified risks.
Incorrect Diagnoses Associated with Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary medications due to incorrect diagnoses being associated with their medication orders. For Resident #33, the facility did not have the correct diagnosis for diabetes mellitus medications, instead associating them with a diagnosis of heart failure. This miscommunication could lead to misdiagnosing and inappropriate treatment. Interviews with the nursing staff revealed that the responsibility for entering the correct diagnosis with medication orders was not consistently managed, leading to potential confusion and treatment errors. Resident #65's medication orders were also incorrectly documented with a diagnosis of type 2 diabetes for medications that were intended to treat other conditions such as hypertension and pain. The medications included Acetaminophen with Codeine, Lisinopril, Metoprolol, Amlodipine, and Apixaban, all of which were incorrectly associated with diabetes. This misalignment of diagnoses and medications could result in inappropriate treatment and monitoring, as well as potential issues with coding and billing. Similarly, Resident #80's medication orders were associated with a diagnosis of acute kidney failure, which was not appropriate for the medications prescribed, including pain relievers and antihypertensives. The incorrect association of diagnoses with medications could hinder proper follow-ups, lab work, and monitoring, potentially leading to adverse drug reactions. Interviews with the nursing staff and administration highlighted a lack of clarity and oversight in ensuring that medications were linked to the correct diagnoses, which could have detrimental effects on resident care.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of antihypertensive medications. The resident, a 59-year-old female with diagnoses including cerebral infarction, hyperlipidemia, and hypertension, was administered medications such as Amlodipine, Carvedilol, Hydralazine, and Losartan despite her blood pressure and/or pulse being outside of the ordered parameters on multiple occasions. These medications were to be held if the resident's systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or pulse was less than 60. On specific dates, the resident received these medications even when her blood pressure readings were below the prescribed thresholds. For instance, on one occasion, Hydralazine was administered when the resident's blood pressure was recorded at 90/52 and 90/50, which was below the hold parameters. Similarly, Amlodipine, Losartan, and Carvedilol were administered when the resident's blood pressure was 103/68, which was also below the required threshold for administration. Interviews with facility staff, including an LVN and the Director of Nursing, revealed that the nursing staff was expected to follow the blood pressure parameters set by the physician. The Director of Nursing stated that if a resident's blood pressure was lower than the set parameters, the physician should be notified to decide whether to hold or administer the medication. However, there was no documentation of any phone calls to the physician regarding the resident's low blood pressure readings on the dates in question.
Menu and Portion Control Deficiencies
Penalty
Summary
The facility failed to ensure that the menus met the nutritional needs of residents and were followed as planned for two consecutive lunch meals. On December 2, 2024, the facility did not serve the posted lunch menu items, substituting breadsticks with sliced white bread and iced cinnamon raisin bars with chocolate chip cookies. On December 3, 2024, the cook did not follow the recipe for cheesy rice, using sliced cheese instead of shredded cheese, and served canned mushroom soup instead of homemade soup. Additionally, the facility did not use the appropriate serving sizes for various meal components, leading to inconsistencies in portion sizes. Interviews with residents and staff revealed dissatisfaction with the portion sizes and the menu not being followed. Resident #52 expressed concerns about small portion sizes and the inconsistency of having enough food for seconds. A grievance filed by a family member of Resident #63 also indicated that the menu was not being followed during mealtimes. Staff interviews highlighted that the kitchen sometimes ran out of food, and substitutions were made without proper documentation or notification to residents. The Dietary Manager and other staff members acknowledged the importance of following recipes and portion sizes to ensure residents' nutritional needs are met. They noted that not adhering to these guidelines could lead to weight loss and other health issues. The facility's policies on portion control, use of recipes, and menu adherence were not effectively implemented, as evidenced by the discrepancies observed during meal services.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. On December 2, 2024, it was noted that food stored in the kitchen refrigerator was not labeled or dated, including a bag of meat and an opened container of blueberry frozen muffin batter. Additionally, cookware in the pantry and main kitchen area had carbon build-up, and containers of cornmeal and sugar were not properly sealed, with cornmeal spilled on the pantry floor. Three white bins used for storing metal lids contained food particles, and the food steamer had a brown film and food particles at the bottom. On December 3, 2024, further observations revealed that the facility did not ensure food was temped before serving. Pureed chicken, ground chicken, canned soup, pureed tomatoes and okra, mashed potatoes, and chicken breast were served without checking their temperatures. The scooper fell into the food during plating, and the Dietary Manager did not practice proper hand hygiene, coughing on her arm and then plating a meal without washing her hands. The juice dispenser and vent were also found to be unclean, with an orange substance inside the handle and brown, fuzzy material on the vent. Interviews with staff, including the Dietary Manager and Director of Nursing, confirmed that the facility's practices did not align with their policies. The staff acknowledged the importance of labeling and dating food items, maintaining kitchen cleanliness, and ensuring food safety through proper temperature checks. The Administrator emphasized the need for food to be served at safe temperatures and for the kitchen to be clean to prevent foodborne illnesses and cross-contamination.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for several residents and a family member. Multiple residents reported that their meals were often served cold, bland, and either overcooked or undercooked. Specific complaints included cold breakfasts and dinners, repetitive meal options, and unappetizing food presentation. A family member also noted that the food did not look appetizing and was inconsistently cooked. During a test meal, surveyors and the Dietary Manager found the mashed potatoes to be bland and the food lukewarm. Interviews with staff revealed that the cook was responsible for preparing warm and flavorful meals, but there were issues with the food's taste and temperature. The Dietary Manager acknowledged that if recipes were followed, the food should be flavorful, and the Director of Nursing noted that recent menu changes had not been well-received by residents. The Administrator emphasized the importance of serving meals that residents would want to eat, and the facility's policy indicated that meals should be nourishing and palatable. The deficiency could potentially lead to weight loss and diminished quality of life for residents.
Infection Control Deficiency Due to Improper Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper glove use and hand hygiene by staff members during resident care. On the specified date, two CNAs, while providing catheter care to a resident with multiple health issues including metabolic encephalopathy, urinary tract infection, and pressure ulcers, did not change their gloves or perform hand hygiene after completing the care. This oversight occurred despite the resident's care plan indicating the need for enhanced barrier precautions due to the presence of a multi-drug resistant organism and other infections. In another instance, a CNA assisting with incontinent care for a resident with Alzheimer's disease and other health conditions failed to change gloves and perform hand hygiene after cleaning the resident and before applying skin protectant cream. The CNA also did not perform hand hygiene after removing gloves and before putting on new ones. This lapse in protocol was observed by a WCLVN, who noted the potential for cross-contamination and infection risk due to improper glove use and lack of hand hygiene. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed the expectation for staff to perform hand hygiene before and after glove use to prevent cross-contamination. The facility's policies on hand hygiene and perineal care emphasize the importance of these practices in reducing infection spread. However, the observed actions of the CNAs did not align with these policies, leading to the identified deficiencies in infection control practices.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #35, had a call light within reach, which is a reasonable accommodation of the resident's needs and preferences. Resident #35, an elderly female with severe impaired cognition and a high fall risk, was observed multiple times over several days with her call light either hanging in the headboard of her bed or on the floor beside her bed, making it inaccessible. This was despite her care plan indicating that she required substantial assistance with activities of daily living and was encouraged to call for assistance to promote her safety. Interviews with various staff members, including CNAs, an LVN, the ADON, the DON, and the ADM, revealed a consensus that all staff members were responsible for ensuring that call lights were accessible to residents. However, it was noted that Resident #35's call light was not consistently within her reach, which could prevent her from alerting staff to her needs. The facility's Call Lights Answering Policy also emphasized the importance of ensuring call lights are within residents' reach, yet this was not adhered to in the case of Resident #35.
Failure to Update Survey Results Book
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was easily accessible to residents, family members, and legal representatives. During a record review, it was found that the survey results book in the lobby contained outdated information, with the most recent state visit result dated 12/01/23, despite a more recent survey having been conducted with an exit date of 08/15/24. This oversight was confirmed during interviews with the RNC and the Administrator, who acknowledged the responsibility for maintaining the survey results book. The RNC admitted there was no policy in place for updating the survey results book and was unsure of how many visits were missed. The Administrator confirmed that it was his responsibility to ensure the survey results books were up to date. The lack of updated survey results could potentially prevent residents and their families from being aware of past and current violation findings from state surveys and investigations conducted in the facility.
Failure to Conduct PASRR Review for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a mental health disorder received an accurate Preadmission Screening and Resident Review (PASRR) following a new diagnosis of major depressive disorder. The resident, a 64-year-old female, was diagnosed with major depressive disorder on 05/13/24, but the facility did not refer her for a PASRR review. This oversight was discovered during a record review and interviews, revealing that the resident had not received the necessary PASRR evaluation, individualized care, or specialized services to address her mental health needs. Interviews with facility staff, including the MDS LPN and the Director of Nursing, highlighted a lack of knowledge and coordination regarding the PASRR process. The MDS LPN acknowledged that a new PASRR Level 1 should have been submitted following the resident's new mental illness diagnosis, but it was not completed. The Director of Nursing admitted to limited knowledge about the PASRR process, and the Administrator expressed reliance on the local mental authority to submit a new PASRR Level 1. The facility's PASRR Pre-Admission Process Flow policy did not adequately address updating the PASRR Level 1 after a new mental illness diagnosis, contributing to the deficiency.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary assistance to maintain good nutrition, grooming, personal, and oral hygiene. This deficiency was observed in a resident with a history of cerebral infarction, hemiplegia, and hemiparesis, who was dependent on staff for transfers from bed to chair. The resident expressed distress over being confined to bed for an entire month, during which she ate, slept, and used the bathroom in bed, indicating a lack of assistance in getting out of bed. The resident's care plan required staff to provide appropriate assistance to promote her safety, yet multiple entries in the ADL function report indicated that transfers did not occur on several occasions throughout November. Interviews with staff, including CNAs and the Director of Nursing, revealed that the resident should have been assisted out of bed upon request, and that failure to do so could lead to negative outcomes such as depression, low self-esteem, and skin breakdown. Despite the resident's requests and the facility's policy, the necessary assistance was not consistently provided. The Director of Nursing acknowledged that the resident preferred a wheelchair over a Geri-chair and that staff were instructed to assist her with a partner due to previous abuse allegations. However, the resident's needs were not met consistently, as evidenced by her prolonged confinement to bed and the lack of documented transfers. The facility's policy on ADL care and transfer techniques was not adhered to, resulting in the resident's unmet needs and emotional distress.
Failure to Ensure Correct Pressure-Relieving Mattress Settings
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. The resident, a 76-year-old female, had a history of metabolic encephalopathy, urinary tract infection, Type II diabetes, and severe pressure ulcers on the right and left buttocks. Despite being on a turning/repositioning program and receiving pressure ulcer care, the resident's pressure-relieving mattress was not set correctly according to her weight, which was 155 pounds, but the mattress was set for 250 pounds. Observations over several days confirmed that the mattress settings were consistently incorrect, which could contribute to the development of avoidable pressure ulcers. Interviews with various staff members, including the Wound Care LVN, Resident Service, Director of Nursing, and the Administrator, revealed a lack of clarity and responsibility regarding who was accountable for ensuring the correct settings on the pressure-relieving mattress. Each staff member had different understandings of their roles, leading to the oversight of the incorrect mattress settings. The facility's policies on support surfaces and wound care emphasized the importance of using pressure redistribution devices according to the manufacturer's instructions to prevent skin breakdown. However, the failure to adhere to these guidelines and ensure the correct mattress settings placed the resident at risk for further skin issues. The staff's lack of awareness and communication about the responsibility for mattress settings contributed to this deficiency.
Inadequate Perineal and Catheter Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents, leading to potential risks of urinary tract infections. Resident #65, a 76-year-old female with multiple diagnoses including metabolic encephalopathy, urinary tract infection, and pressure ulcers, was observed receiving inadequate catheter care. During the procedure, CNA E and CNA L did not follow the facility's policy for catheter care, as they failed to properly clean the resident's perineal area and catheter tubing. Additionally, when the disposable wipes fell on the floor, they were picked up and used again without replacing them, compromising infection control measures. Resident #63, an 84-year-old female with Alzheimer's disease and other conditions, was found with feces on her thigh and brown stains on her brief, indicating improper cleaning during previous incontinence care. During a skin assessment, WCLVN G noted that CNA F wiped towards the resident's vagina instead of away, which is against the facility's perineal care policy. This improper technique could lead to skin breakdown and increase the risk of infection. Interviews with the Director of Nursing and the Administrator revealed that the staff did not adhere to the expected standards of care, including cleaning from front to back and ensuring residents were clean after incontinence care. The facility's Perineal Care policy outlines specific procedures to prevent skin breakdown and infection, which were not followed in these instances, placing the residents at risk for urinary tract infections.
Failure to Follow Dietary Recommendations and Monitor Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, identified as Resident #81, who was on enteral feeding due to dysphagia following a cerebral infarction. The dietician recommended a change in the resident's tube feeding formula to Glucerna 1.5 at 60 ml/hr starting in September, but the facility continued to administer Glucerna 1.2. Additionally, the dietician advised weekly weight monitoring beginning in November, which was not implemented. These oversights were compounded by a lack of follow-up on a significant 9.12% weight loss over three months. Observations and interviews revealed that the facility's staff, including RN A, were unaware of the dietician's recommendations and the resident's weight loss until it was brought to their attention during the survey. The RN acknowledged that the dietary recommendations were not followed and that the resident's weight loss was not addressed. The facility's process for handling dietary recommendations was unclear, with staff unsure of who was responsible for ensuring these recommendations were acted upon. The dietician had communicated her recommendations via email to the DON, ADON, and other relevant staff, but these were not acted upon. Interviews with the DON, ADON, and other staff members highlighted a breakdown in communication and responsibility. The DON admitted to missing the dietician's emails and acknowledged that the previous ADON had not been managing the dietary recommendations effectively. The ADON, who was new to the facility, was not aware of the process for handling dietary recommendations and weight loss, leading to a failure in addressing the resident's nutritional needs. The facility's policies on enteral nutrition and weight monitoring did not adequately address the need for following dietary recommendations or ensuring physician orders were updated accordingly.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary psychotropic drugs. For one resident, there was no appropriate diagnosis entered for the prescribed Escitalopram, which is commonly used to treat depression and anxiety. Instead, the medication was incorrectly associated with a diagnosis of Type 2 diabetes. This discrepancy was noted in the resident's medication administration records, where the resident received 30 doses of Escitalopram without a proper diagnosis to justify its use. Another resident was prescribed multiple psychotropic medications, including Venlafaxine, Divalproex, and Mirtazapine, for major depressive disorder. However, there was a lack of behavior monitoring to assess the effectiveness of these medications. The behavior monitoring log for this resident did not reflect any data, despite the requirement for nurses to document behaviors every shift. Interviews with nursing staff revealed that behavior monitoring was supposed to be documented in the facility's electronic charting system, but this was not done for the resident in question. The Director of Nursing and other staff acknowledged the importance of having correct diagnoses for medications and the necessity of behavior monitoring to evaluate treatment efficacy. However, the facility's failure to document behavior monitoring and ensure appropriate diagnoses for psychotropic medications led to deficiencies in the care provided to these residents. The facility's policy on psychotropic drug use emphasized the need for supporting diagnoses and documentation of non-drug interventions, which were not adequately followed in these cases.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident #77, who expressed a desire for specific breakfast items, including boiled eggs, cereal, toast, and milk. Despite the resident's clear communication of these preferences, the facility did not provide the requested items on multiple occasions. On the mornings of December 3rd, 4th, and 5th, the resident did not receive boiled eggs as requested, and on one occasion, scrambled eggs were listed on the meal ticket but were not provided. This lack of accommodation was confirmed through interviews with the resident and observations of the meal trays. The deficiency was further compounded by the facility's failure to obtain the resident's meal choices for each meal. Interviews with staff, including CNAs and the Dietary Manager, revealed that the 2nd shift CNAs were responsible for collecting meal preferences but were not consistently doing so. This resulted in residents receiving the default posted meal instead of their preferred choices. The Dietary Manager acknowledged the issue and noted that it had been previously addressed with nursing administration but had not been sustained. The Director of Nursing and the Administrator both recognized the importance of honoring residents' food preferences, citing potential impacts on residents' quality of life and caloric intake. The facility's policies indicated that trays should be checked for special requests and that meals should be tailored to residents' nutritional needs and preferences. However, these policies were not effectively implemented, leading to the deficiency in accommodating Resident #77's meal preferences.
Resident Exposed Due to CNA's Inaction
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as required by resident rights regulations. The incident involved a resident with dementia and anxiety disorder, who had a moderate cognitive impairment. The resident reported that a CNA left her exposed to the hallway after she requested the CNA to leave her room. The CNA admitted to leaving the resident's sheet and blanket pulled back, leaving the resident exposed, and did not close the door. The resident expressed feeling upset and worried about being seen by others. Interviews with facility staff, including the Activity Director, ADON, DON, and Administrator, confirmed the incident and the expectation that the resident should have been covered and the door closed to ensure privacy. The facility's policy on perineal care emphasized the importance of draping residents with linens to provide privacy. The failure to adhere to these policies and procedures resulted in a deficiency related to the resident's right to dignity and privacy.
Deficiencies in Care Plan Implementation for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which resulted in deficiencies in their care. Resident #63, an 84-year-old female with Alzheimer's disease, muscle weakness, and pain, was observed without a pillow in her wheelchair on multiple occasions, despite her care plan intervention requiring it for comfort and to prevent skin breakdown. The absence of the pillow was noted during observations on two consecutive days, and it was acknowledged that the resident often wiggled in her chair, which necessitated the use of a pillow for proper positioning. Resident #80, a 59-year-old female with cerebral infarction, hemiplegia, and dysphagia, had a care plan intervention to monitor her oral intake due to her altered nutritional status. However, there was a lack of documentation of her meal intake throughout November 2024, with numerous instances of missing records for breakfast, lunch, and dinner. This failure to document her intake could hinder the facility's ability to monitor her nutritional status and address any potential weight loss concerns. Interviews with facility staff, including an LVN, CNA, and the Director of Nursing, revealed that the CNAs were responsible for documenting meal intakes, and the LVNs were to ensure this documentation was completed. The staff acknowledged the importance of following care plan interventions and the role of documentation in tracking residents' nutritional status and preventing issues such as weight loss. The facility's policies on care planning and meal intake documentation emphasized the need for individualized care and monitoring, which were not adhered to in these cases.
Failure in Accurate Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the administration of Hydralazine, a medication used to treat high blood pressure. The resident, a 59-year-old female with a history of cerebral infarction and hypertension, was supposed to have her blood pressure and pulse checked before each administration of the medication. However, the records showed repeated identical readings for blood pressure and pulse on multiple occasions, suggesting that the checks were not performed accurately or at all. This was confirmed through interviews with the LVN and the Director of Nursing, who both acknowledged that the same readings could indicate falsification and that proper monitoring was essential to prevent potential harm to the resident. The resident's care plan required monitoring of blood pressure every shift, and the medication administration record specified holding the medication if certain blood pressure or pulse thresholds were not met. Despite these requirements, the facility's staff failed to ensure accurate and new readings were taken before administering the medication. Interviews with the LVN and the Administrator highlighted the importance of following physician orders and the potential risks of not doing so, such as the resident experiencing adverse effects if the medication was administered when not needed.
Failure to Update Care Plans Following Significant Changes
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for four residents were reviewed and revised by the interdisciplinary team following significant changes in their conditions. Resident #18 exhibited physically aggressive behavior towards another resident, but the care plan did not include any interventions for managing such behavior. Despite the incident being documented in the nurse's notes, the care plan remained unchanged, leaving staff without guidance on how to address potential future occurrences. Resident #6 experienced a fall resulting in a major injury, specifically a hip fracture, yet the care plan was not updated to include interventions for managing the fracture or preventing further falls. Although the fall was discussed in clinical meetings, the necessary updates to the care plan were not made, indicating a lapse in communication and follow-through. Similarly, Resident #8's care plan was not revised to include interventions such as a scoop mattress and fall mat after a fall that resulted in a fractured nose and head injury, despite these interventions being noted in the incident report. Resident #10 also suffered a fall with a closed head injury, but the care plan did not reflect the use of a fall mat and pommel cushion, which were observed to be in place during a later inspection. The MDS Coordinator and DON acknowledged the importance of updating care plans promptly to ensure staff are informed of current interventions, but the failure to do so left staff without critical information needed to prevent further incidents. The facility's policy requires care plans to be revised as residents' conditions change, but this was not adhered to in these cases.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination and to make healthcare decisions for herself. This deficiency involved a resident who was not allowed to go to the hospital when she requested it. The resident, who had a BIMS score indicating no cognitive impairment, was on dialysis and had complex medical conditions including peripheral vascular disease, sepsis, and diabetes mellitus type II. On the day of the incident, the resident felt unwell and experienced confusion and hallucinations, which she recognized as potential signs of a medical issue due to her dialysis treatment. Despite her request to be sent to the hospital, the agency nurse, LVN M, refused to call an ambulance, stating that the resident was medically stable and that it would be against medical advice to send her out. The resident's family attempted to intervene by calling the facility multiple times, but the nurse did not comply with their requests and even hung up on them. The nurse checked the resident's vital signs and consulted with an MD, who reportedly advised against sending the resident to the hospital, although no documentation of this consultation or the vital signs was recorded. Eventually, a family member came to the facility and called an ambulance himself. The facility's Director of Nursing and Administrator were aware of the incident, and the nurse was subsequently removed from the schedule.
Failure to Protect Residents from Abuse by CNAs
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by incidents involving two certified nursing assistants (CNAs). In the first incident, a CNA was reported to have shaken a resident's wheelchair while providing incontinent care. The resident, who had severe cognitive impairment due to dementia, was unable to recall the event. The incident was reported by another CNA who witnessed the event and noted that the involved CNA was visibly upset during the care process. In the second incident, another CNA forcefully pushed a resident's wheelchair across a hallway. The resident, who had cerebral palsy and severe cognitive impairment, was being combative at the time. A licensed vocational nurse (LVN) witnessed the incident and intervened, noting that the resident could have been injured. The CNA involved did not deny the action but stated she was reacting to being hit by the resident. Both incidents were documented in the facility's Potential Incident Report (PIR) and involved the suspension and eventual termination of the CNAs involved. The facility's abuse policy emphasizes the right of residents to be free from abuse by anyone, including facility staff. The incidents highlight a failure to adhere to this policy, resulting in potential harm to the residents involved.
Inadequate Discharge Planning Leads to Unsafe Transition
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, leading to an unsafe transition to post-discharge care. The resident, a female with peripheral vascular disease, sepsis, and diabetes mellitus type II, was admitted to the facility and required substantial assistance for daily activities. Despite planning to return home after discharge, there were no care plans or discharge instructions documented in her electronic health record. The resident reported receiving no written or oral instructions on her medication or treatment regimen before discharge, and upon returning home, she lacked the necessary durable medical equipment (DME) such as a hospital bed and mechanical lift. Interviews revealed that the social services department had not communicated the resident's early discharge to the home health or DME providers, resulting in a lack of essential support at home. The resident's family was able to assist with some tasks, but the absence of DME and medication instructions led to her readmission to the hospital for hypokalemia. The facility's discharge policy required the provision of home health and DME for a safe living environment post-discharge, which was not adhered to in this case.
Inadequate Supervision Leads to Resident's Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with severe cognitive impairment and a high risk of elopement. The resident, who had a history of dementia, atrial fibrillation, and diabetes mellitus type II, was admitted with a high elopement risk and required partial to moderate assistance with activities of daily living. Despite being identified as a high elopement risk, the resident managed to exit the facility and fell from his wheelchair, sustaining a hematoma and abrasion to his head. The incident occurred when staff were occupied with meal service, and the resident was not adequately supervised. Interviews with staff revealed that the resident frequently attempted to find exits and was difficult to redirect due to his dementia. Staff were aware of his elopement risk and attempted to monitor him closely, but during busy times such as meal service, it was challenging to maintain constant supervision. The Director of Nursing acknowledged the resident's high risk of elopement and the facility's inability to meet his needs, leading to his discharge to a secured unit. The facility's fall prevention policy emphasized evaluating residents for fall risk and developing interventions, but these measures were insufficient in preventing the resident's accident.
Failure to Administer IV Antibiotics Timely
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of IV antibiotics. A resident, who was admitted with diagnoses including peripheral vascular disease, sepsis, and diabetes mellitus type II, was supposed to continue receiving vancomycin and meropenem as per discharge instructions from an acute hospital. However, the facility did not initiate the meropenem treatment until three days after the prescribed start date. This delay occurred because the nurse responsible for the resident's admission noted the need for clarification on the antibiotic order but did not follow up, and the oversight was not caught until a chart audit was conducted. The delay in administering meropenem was attributed to the discharge orders being overlooked, and the lack of a care plan for IV antibiotics in the resident's electronic health record. The resident continued to receive vancomycin during dialysis, and no acute issues were observed by the Director of Nursing. The nurse practitioner involved stated that the missed doses did not result in harm to the resident, as there were no signs of physical decline. The facility's policy on administering medications emphasizes the importance of timely and accurate medication administration, which was not adhered to in this instance.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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