San Antonio North Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 501 Ogden, San Antonio, Texas 78212
- CMS Provider Number
- 455817
- Inspections on file
- 61
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at San Antonio North Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, bipolar disorder, quadriplegia, and intact cognition alleged that three unknown men sexually abused her by inserting a metal object between her vagina and rectum. Nursing staff documented the allegation, notified the Administrator and DON, and performed a head‑to‑toe assessment without finding new injuries; one LVN reported offering an ER visit for a SANE exam, while another did not recall if this occurred. The MHNP, aware of the allegation and the resident’s history of delusions, performed only a psychological evaluation and did not order an ER visit, stating it was the facility’s responsibility to notify law enforcement and HHS. The DON and Administrator acknowledged knowing of the allegation but chose not to report it to the State Survey Agency or law enforcement, despite a written policy requiring all abuse allegations to be reported immediately, resulting in a failure to timely report the suspected abuse.
A resident with heart failure and end-stage CKD, dependent on staff for ADLs and transfers, repeatedly reported through the Ombudsman that call lights were ignored, she was left on a bedpan for extended periods, food was not provided in a timely manner, leg wraps were painful or coming off and not re-wrapped as promised, and that certain CNAs and an LVN provided improper or disrespectful care. The Ombudsman sent multiple grievance emails to the Administrator detailing these issues, including concerns about improper perineal hygiene, failure to assist off the bedpan, scolding for using the call light, and yelling and accusations related to leg wraps. Despite these communications and the facility’s written grievance policy requiring the grievance official to receive, track, investigate, and document grievances and issue written decisions, the facility’s grievance records contained no entries for this resident, and the Administrator acknowledged not documenting any grievances from the Ombudsman’s emails.
Staff on two medication carts pre-poured and stored multiple oral medications in unlabeled plastic cups with only handwritten resident names, instead of keeping them in pharmacy-labeled containers and administering them immediately per policy. On one cart, a medication aide stored risperidone, melatonin, quetiapine, and famotidine in a cup when a resident was unavailable. On another cart, an LVN stored Depakote 250 mg, Depakote 500 mg, and carbamazepine of unknown strength in a cup while taking a break. Both staff acknowledged that pre-pouring was not consistent with professional standards, and leadership confirmed that facility policy requires immediate administration following verification of the six rights of medication administration.
A deaf and mute resident with traumatic brain injury, schizoaffective disorder, and paraplegia was not provided effective communication to understand and participate in care and treatment. Although orders and the care plan called for sign language, interpreter services, and use of a communication device, staff largely relied on hand gestures and head nods, and key staff were unaware of or did not implement video relay services. The resident had limited reading and writing skills and could not lip read, contrary to assumptions by leadership. Staff identified as interpreters had only basic ASL skills and no formal training or certification, and there were no clear Kardex or care plan instructions for consistent use of qualified ASL or VRS services, resulting in ineffective communication about the resident’s health status and treatments.
A hospice RN alleged that a male hospice resident with severe cognitive impairment, incontinence, and hemorrhoids had been sexually assaulted after blood was found on his bedding and brief during incontinent care. Nursing staff notified hospice and, per hospice direction, sent the resident to the ER for a SANE exam, which later found no evidence of sexual assault and attributed the bleeding to grade 2 hemorrhoids. The ADON reported not knowing whether the allegation had been reported to the State Agency, and the Administrator admitted being aware of the sexual abuse allegation and not reporting it, contrary to the facility’s abuse policy requiring immediate reporting of all alleged abuse to the State Agency and other authorities within specified time frames.
A resident receiving hospice care with severe cognitive impairment, incontinence, and a history of hemorrhoids was found by a CNA to have blood on bedding and an adult brief. An LVN notified hospice, and a hospice RN alleged possible sexual assault and approved transfer to the ER for a SANE exam. The ADON and Administrator were informed of the suspected sexual abuse. A subsequent SANE exam found no evidence of sexual assault and attributed bleeding to hemorrhoids. Despite the allegation and the facility’s written policy requiring immediate investigation and reporting of all alleged abuse to the State Agency and other authorities within specified time frames, the Administrator did not report the allegation or submit an investigation report.
A resident with deaf non-speaking status, traumatic brain injury, schizoaffective disorder bipolar type, and paraplegia did not have a comprehensive, person-centered communication care plan with measurable objectives and clear interventions. Although physician orders and facility leadership indicated the resident used ASL, interpreter services, and an iPad with a visual relay service, the care plan and CNA Kardex lacked specific instructions for using the ASL phone/VRS, did not list the VRS number, and did not detail how staff should communicate when they did not know ASL. CNAs and an LVN reported relying on hand gestures and head nods and were unaware of the VRS system, while the Ombudsman and a relative reported the resident had poor reading and writing skills and could not lip read. The facility’s own comprehensive care plan policy required resident-specific interventions and identification of communication methods, but these elements were not fully incorporated into the resident’s plan of care.
Surveyors found that an LVN was using a medication cart containing a covered water pitcher and small cups of pudding and jelly that were not labeled or dated, despite facility policy and professional standards requiring fluids and food on the cart to be covered and dated. The LVN stated he had obtained and prepared these items earlier in his shift but had not labeled them, and the ADON confirmed that staff are trained to label water, pudding, and jelly used to assist residents with medication administration to indicate when they were prepared.
A resident with acute and chronic kidney disease, muscle weakness, incontinence, and a need for assistance with personal care was found to be living in a room with a persistent, strong urine odor detectable from the hallway and markedly stronger inside the room. Surveyors observed an unmade bed with a yellowish/brown mattress protector and sheet and later noted that, even after the bed was made, the urine odor remained overwhelming. Staff interviews revealed that housekeeping cleaned the room multiple times daily and had already replaced the mattress, but the odor persisted and staff frequently complained about it. Maintenance acknowledged the room had smelled this way for an extended period and stated that, although they continued cleaning, the flooring could not be stripped. Administration reported ongoing issues with the resident not getting out of bed to use the toilet and refusing to use provided briefs, contributing to the continued unsanitary and uncomfortable environment.
The facility failed to maintain safe and adequate lighting and electrical service in three resident rooms, resulting in nonfunctional over‑bed lights and intermittent or absent power to room lights and televisions. One cognitively intact male resident with traumatic brain injury, PTSD, and a fall risk reported having no electricity in his room for weeks, with nonworking room lights, over‑bed lights, and television, and described nearly falling while going to the bathroom in the dark. Another male resident with left‑sided hemiplegia, diabetes, major depressive disorder, and PTSD reported his television repeatedly shorting out in a dark room where the over‑bed light did not work. A female resident with hypertension, anxiety, age‑related physical disability, and a history of falls related to gait and balance problems reported that her bathroom light sometimes did not work and described falls when attempting to return to bed and when the bathroom light was out. Observations confirmed dark rooms partially lit only by hallway light, nonfunctional over‑bed lights, and electrical issues, despite a facility policy requiring adequate lighting and maintenance rounds to ensure functioning lights.
Three residents with varying levels of cognitive function and multiple comorbidities reported abusive interactions with an LVN, including verbal disrespect, bullying behavior, and physical contact. One resident described the LVN as a bully who inappropriately questioned her about giving $200 to another resident. Another resident, who used a wheelchair and was cognitively intact, reported that the LVN unplugged the television while he was playing chess, blocked his access to the nurses’ station and the Administrator’s phone number with a med cart, and grabbed his arm and pushed his chest, which staff corroborated. A third resident with schizophrenia and severe cognitive impairment recalled that the LVN refused to let him go outside to listen to his radio after he had signed himself out and told him to shut up and go back upstairs, while he also told her to shut up. These actions show that residents were not protected from verbal and physical abuse by staff.
A staff member worked 88 shifts administering medications and performing duties as a Medication Aide without holding a valid MA certificate or CNA certification. The staff member was incorrectly listed as an LVN, and her GVN permit had expired. Despite this, she continued to work under RN supervision, and her credentials were not properly verified or maintained by facility leadership. No negative outcomes were documented for residents during this period.
A resident with chronic pain and a history of self-harm was receiving opioid medication when pharmacy recommendations regarding their drug regimen were communicated to facility staff but not documented as reviewed or addressed by a provider. The ADON forwarded the recommendations but did not follow up when no response was received, and the physician was unaware of the outstanding recommendations. Facility policy required such documentation and follow-up, but this was not completed.
Two residents experienced deficiencies in their bathroom environments, including an unpainted and scratched door, a rusted door post, and an unsecured toilet. These issues were confirmed by facility leadership and were not addressed in accordance with the facility's preventative maintenance policy.
Surveyors identified deficiencies in kitchen cleanliness and maintenance, including dirty ceiling tiles, a missing light bulb, a rusted ceiling vent, and damaged floor molding and wall in the employee bathroom. Staff interviews confirmed awareness of these issues, which were found to be inconsistent with professional standards for food service safety.
A resident's Medication Administration Record contained blank spaces for medication administration and monitoring on a specific date, with no corresponding progress notes. The assigned nurse did not document whether medications or required monitoring were provided or refused, despite facility policy and physician orders requiring complete and timely documentation. The DON confirmed the lack of documentation and the expectation for staff to record all medication-related actions.
Surveyors found that a dumpster had its sliding door left open and was full of garbage bags. The Food Service Director acknowledged the requirement to keep lids closed for pest control, while the Administrator was unaware of the specific regulation. Facility policy and federal food code require garbage containers to be kept covered.
The Maintenance and Housekeeping Office, containing tools and cleaning equipment, was found open and unattended near resident rooms and the nurses' desk. Staff confirmed the office was usually kept locked due to the presence of potentially unsafe items, but the Maintenance Director left it open, believing it was safe because a housekeeper was nearby. The DON stated the expectation was for the office to be secured at all times.
A resident with moderate intellectual disability, who requires cues for toileting, was found sitting in urine in a dining room chair after staff failed to provide timely incontinent care. The resident was last changed before dinner and not checked again until family members discovered her wet and reported it to staff, who then provided care. Facility policy requires prompt assistance with hygiene and toileting, but this was not followed in the incident.
A resident with multiple chronic conditions did not have wound care treatments consistently documented on the TAR, with several treatment days left blank. The responsible nurse stated that documentation was sometimes missed due to absence or oversight, and refusals by the resident were not always recorded. The DON confirmed these documentation gaps, which were not in line with facility policy requiring complete and accurate records of wound care.
A medication cart was found unlocked and unattended near the nurses' station, containing both OTC and resident medications, while multiple residents and staff were present in the area. The assigned LVN confirmed the cart should not have been left unlocked, and facility leadership reiterated that medication carts must be secured when unattended, as per facility policy.
A resident with a history of cerebral infarction, kidney disease, and dementia was not assisted in obtaining dental services after her top dentures were reported missing. Despite family notification and care plan documentation of oral health risks, facility staff were unaware of the missing dentures and did not arrange for dental care, leaving the resident without her upper dentures and at risk while continuing to eat a regular diet.
Three residents in the facility were found without access to their call lights, which were placed out of reach. One resident with severe cognitive impairment had her call light four feet away, another resident with no cognitive impairment had his call light behind his bed, and a third resident with Alzheimer's and legal blindness had his call light under a wheelchair. Staff interviews confirmed the expectation for call lights to be accessible, but this was not adhered to, leading to the deficiency.
A resident with severe cognitive impairment did not have a privacy curtain during incontinent care, compromising her privacy. Despite staff awareness and facility policies emphasizing privacy, the curtain had been missing for an extended period. The Housekeeping Director acknowledged the issue, and the facility's training on privacy was not effectively implemented.
A resident with multiple health conditions did not have accurate documentation of wound care treatments in their TAR, as required by professional standards. The facility failed to ensure that the treatments were properly recorded, with nursing staff not documenting the care provided. This lack of documentation could risk the resident not receiving appropriate care.
A resident with dementia and schizoaffective disorder was transferred to a hospital without notifying the legal guardian, leading to a deficiency in discharge rights. The facility assumed the hospital would communicate with the guardian, but no documentation of this was found. The resident was later admitted to another nursing home without the guardian's knowledge.
Two residents requiring oxygen therapy were found with empty humidifier bottles on their oxygen concentrators, which had not been changed as required. One resident had intact cognition and required oxygen for shortness of breath, while the other had severe cognitive impairment and multiple health issues. The night shift was responsible for changing the bottles weekly, but this was not done, posing a risk of dry nasal passages.
The facility failed to maintain a safe and sanitary environment, with issues including a broken electrical outlet, a roof leak causing water accumulation, missing floor paneling, and stained ceiling panels. The Maintenance Director and Administrator were unaware of some issues until the day of observation.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to call for assistance. One resident with schizoaffective disorder and unsteadiness had her call light wrapped on the wall, while another with muscle weakness and diabetes had his on the nightstand, both out of reach. The CNA admitted to not repositioning the call lights, and the DON acknowledged the importance of accessibility to prevent falls.
The facility failed to provide a safe, clean, and homelike environment for two residents. One resident's restroom had barrels of soiled linens and trash, while another's shower area was soiled with a dark brown substance. These conditions were confirmed by the Director of Housekeeping and the ADON, respectively.
A resident with a history of muscle weakness, insomnia, and Type II Diabetes was observed smoking an electronic cigarette in his room, despite being assessed as a supervised smoker. The facility's policy required smoking in designated areas, but the resident stated he makes his own rules. Staff interviews confirmed the resident's non-compliance and the potential fire hazard.
A resident was prescribed Xanax for anxiety on a PRN basis indefinitely, contrary to the facility's policy limiting such orders to 14 days. The resident, with moderately impaired cognition and multiple diagnoses, was at risk due to this oversight. The DON confirmed the error, noting that the ADON was responsible for daily oversight, but monitoring was done randomly, leading to the deficiency.
A facility failed to ensure safe storage of food in a resident's personal refrigerator, as observed by surveyors. The refrigerator contained open and undated lunch meat, which was confirmed by a CNA and the DON. The facility's policy requires labeling and dating of perishable foods, but this was not being monitored by the night shift nurses.
The facility failed to maintain proper garbage storage, as observed on two occasions where a garbage bin lid was left open, exposing waste. The Dietary Director and Administrator acknowledged the requirement for lids to remain closed to prevent pest issues, aligning with the facility's policy on garbage disposal.
A resident with severe cognitive impairment and complex medical conditions did not receive adequate foot care or access to podiatry services, resulting in overgrown toenails and a sore on her toe. Despite requests from the family and orders for podiatry services, the resident was not seen by a podiatrist during their visits to the facility. The facility's staff failed to document or provide routine nail care, leading to missed care and potential health risks.
A resident with dementia, depression, and anxiety was not monitored according to his care plan, which required staff to report his fear of being alone. An LVN failed to document or report this fear, leading to the resident's suicide attempt. The facility's failure to implement a comprehensive care plan resulted in Immediate Jeopardy.
A resident with dementia, depression, and anxiety in a LTC facility displayed increased fear and requested staff presence, but interventions were not implemented, leading to a suicide attempt. Despite a care plan requiring monitoring and psychiatric consultation, behavior monitoring was not conducted, and staff failed to communicate the resident's fear and suicidal ideation to the psychiatric team. This deficiency was identified as an Immediate Jeopardy situation.
The facility failed to monitor residents for side effects and effectiveness of psychotropic medications, as required by their care plans. Six residents with various cognitive and mood disorders were not monitored for target behavior symptoms or side effects, despite being prescribed multiple psychotropic medications. Interviews with staff indicated a belief in adequate monitoring, but no specific orders or documentation supported this.
A resident with dementia, depression, and anxiety attempted suicide by using a shirt as a noose. Despite the incident being documented and the resident being hospitalized, the facility failed to report the event to the State Survey Agency within the required timeframe. The administrator did not consider the incident reportable, contrary to facility policies and state guidelines.
A resident with dementia and depression attempted suicide, but the LTC facility failed to investigate the incident thoroughly. Despite the resident's admission to a hospital for a suicide attempt, the facility did not document or investigate the event, citing inconsistencies in staff reports. The facility's policies require investigation and reporting of such incidents, but these were not followed.
A facility failed to maintain a medication error rate below 5%, resulting in a 44% error rate. A resident with multiple health conditions received medications over an hour and a half late, potentially affecting therapeutic outcomes. The CMA responsible reported consistent delays due to workload but did not escalate the issue to higher management. Facility policies lacked guidance on administration timeliness.
Failure to Timely Report Resident Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of sexual abuse to the State Survey Agency as required by its abuse, neglect, and exploitation policy. A female resident with schizoaffective disorder, bipolar disorder, anxiety, quadriplegia, chronic pain, and a BIMS score of 15 (no cognitive impairment) alleged on 4/1/16 that three unknown men sexually abused her by inserting a metal rod between her vagina and rectum. Nursing notes documented the allegation, and the DON recorded that the resident made an allegation of sexual abuse involving a metal rod. The facility’s abuse policy required reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable, immediately but no later than two hours after the allegation is made if the events involve abuse. Despite this policy, the allegation from 4/1/16 was not reported to the State Survey Agency (HHSC) or law enforcement. The grievance log for April did not list the alleged sexual abuse as a grievance. Interviews showed that staff, including LVN A and LVN B, were aware of the allegation and notified the Administrator and DON, and a head‑to‑toe assessment was performed with no new skin issues noted. The resident was reportedly offered an ER visit for a SANE exam by one LVN, while another LVN did not recall if such an exam was offered, and there was no documentation that the resident was sent to the ER. The MHNP confirmed being informed of the allegation and stated she conducted a psychological evaluation only and did not order an ER visit, indicating it was up to the facility to notify law enforcement and HHS. The DON acknowledged that the first allegation of sexual abuse on 4/1/16 was conveyed to her by the MHNP and that law enforcement was not called because the resident had a history of making false sexual allegations and the assessment revealed no findings of sexual abuse. The Administrator confirmed he did not contact law enforcement or HHS regarding the 4/1/16 allegation, citing the MHNP’s view that the allegation was not in the realm of possibility and the lack of identified perpetrators beyond “three unknown men.” The ADON stated she was not aware of the first allegation and reiterated that facility policy required notifying the Abuse Coordinator and sending applicable reports to law enforcement and HHS when any resident made an outcry of sexual abuse. The facility did report a later, second allegation of sexual abuse on 4/14/16, but the first allegation on 4/1/16 was not reported as required, resulting in noncompliance with mandatory reporting requirements for abuse allegations.
Failure to Document and Address Resident Grievances Communicated Through Ombudsman
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to voice grievances without discrimination or reprisal and to make prompt efforts to resolve those grievances. The facility’s grievance log from 01/01/2026 through 03/31/2026 contained no documented grievances for Resident #2, despite multiple written complaints submitted via the local Ombudsman. The Ombudsman sent 11 grievance emails to the Administrator detailing the resident’s concerns, including prolonged waits on a bedpan, ignored call lights, improper incontinent care, unaddressed pain and discomfort from leg wraps, food not being provided in a timely manner, and staff behavior perceived as rude, scolding, or yelling. None of these grievances were documented in the facility’s grievance records as required by the facility’s grievance policy. Resident #2 was a long-term care resident, a [AGE]-year-old female with diagnoses including hypertensive heart disease with heart failure and end-stage chronic kidney disease. She was dependent on staff for ADLs and transfers. The Ombudsman’s emails reported repeated instances where the resident stated she had been left on a bedpan for extended periods (ranging from approximately 25–50 minutes or more) and that her call light was not being answered. The Ombudsman also reported that the resident’s calls to the facility’s main number were not answered and that the voicemail box was full. Additional grievances included that a grilled cheese sandwich had been left on the resident’s dresser without being given to her, that leg wraps were too tight and painful and were not re-wrapped as promised by nursing staff, and that leg wraps coming off her feet were not tended to as requested. The Ombudsman further relayed grievances that specific CNAs and an LVN were providing care in ways the resident and her roommate found unacceptable. One CNA was reported to have cleaned the resident by wiping from rectum to vagina, which the Ombudsman identified as improper hygiene, and both the resident and her roommate requested that this CNA no longer attend to them. Another CNA was reported to repeatedly fail to respond to the resident’s call light or assist her off the bedpan, requiring another CNA from a different hall to help. The resident also complained that this CNA scolded her for using the call light. The Ombudsman reported that an LVN failed to return to re-wrap the resident’s leg after promising to do so and later allegedly yelled at the resident and accused her of tearing off her leg wraps, which the resident viewed as a violation of her dignity and respect. During interviews, the Administrator and DON acknowledged that Resident #2 had refused to allow them into her room and used the Ombudsman as her representative, and the Ombudsman stated that despite repeated verbal and emailed advocacy, the resident’s grievances were not addressed. The Administrator stated he had not documented any grievances from the Ombudsman’s emails, even though the facility’s grievance policy required the grievance official to receive, track, investigate, and document grievances and issue written grievance decisions to the resident. During an observation and interview, Resident #2 stated she was not being helped by staff, that her call lights were ignored, and that she was left on the bedpan for hours. She reported using her cell phone to call the facility without success and then calling the Ombudsman to complain. She reiterated that one CNA was rude and did not provide incontinent care properly or kindly and that she had requested this CNA no longer provide care to her, preferring another CNA instead. These statements, combined with the absence of any corresponding entries in the facility’s grievance documentation and the content of the Ombudsman’s emails, demonstrate that the facility did not follow its own grievance policy to document, investigate, and attempt to resolve the resident’s grievances, and did not ensure the resident’s right to voice grievances without fear of discrimination or reprisal was honored.
Improper Pre-Pouring and Storage of Medications on Two Medication Carts
Penalty
Summary
The deficiency involves failure to ensure drugs and biologicals were labeled and stored in accordance with professional standards and facility policy, specifically related to pre-poured medications on two medication carts. On the 200-hall, a Medication Aide (MA) was observed at her cart during a medication pass and stated she had intended to administer medications to a resident who was unavailable due to receiving a shower. To avoid wasting the medications, she placed four pills—identified as risperidone, melatonin, quetiapine, and famotidine—into a small clear plastic medication cup, wrote the resident’s name on the cup, and stored it in the first drawer of the cart with other medications instead of keeping them in pharmacy-labeled containers. The MA acknowledged that pre-pouring medications was not acceptable professional practice and stated that this could lead to a potential medication error. On the 400-hall, an LVN was observed at her medication cart after returning from a brief lunch break. She opened the cart and showed a small clear plastic cup containing three pills, with a handwritten resident name on the cup. She identified the medications as Depakote 250 mg, Depakote 500 mg, and carbamazepine of an unknown strength, stating she would need to look up the carbamazepine dosage. The LVN reported she had pre-poured the medications when the resident was not available and then stored them while she took her break, intending to administer them upon her return. The ADON stated that facility training and expectations require staff to identify the resident and immediately dispense and administer medications, and that pre-pouring is against policy and could lead to medication errors. The facility’s Medication Administration policy requires medications to be administered as ordered and in accordance with professional standards, including verifying the six rights of medication administration and comparing the medication source with the MAR before administration.
Failure to Provide Effective Communication for Deaf Resident Regarding Care and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a deaf and mute resident was fully informed of and able to participate in his treatment and health status through effective communication methods he could understand. The resident was admitted with diagnoses including deaf non-speaking status, traumatic brain injury, schizoaffective disorder bipolar type, and paraplegia. His admission MDS identified him as a long-term care resident needing ADL safety supports. Physician orders directed the facility to use hand-talk for communication/interpretation, and the care plan documented impaired communication due to deafness and muteness, noting that the resident refused a communication board and preferred someone who could use sign language. The care plan referenced interpreter services via a video ASL contractor and set a goal for the resident to communicate basic needs using a communication/interpreter device, with interventions including sign language, writing, interpreter/communication devices, and interpreter services. Despite these documented needs and interventions, interviews and observations showed that effective communication methods were not consistently implemented or understood by staff. The Administrator and DON stated the resident could communicate with hand gestures, read and write, and read lips, and that the SW could communicate with ASL and interpreter services were available as needed. They also reported the resident had an iPad with a visual interpreter service through Sorenson’s VRS and that the resident’s VRS phone number was on the admission record. However, the Ombudsman reported learning from the resident and a relative that the resident had poor reading, writing, and spelling skills, could not lip read, and had lost his hearing early in life before learning to speak, read, or write. The Ombudsman also stated the facility had failed to assist the resident with his iPad and VRS service. Further interviews with direct care staff confirmed gaps in communication supports. CNAs caring for the resident reported there were no instructions in the CNA Kardex for communicating with the resident by phone and they were unaware of any VRS system; they relied on hand gestures and head nods and did not understand ASL. The charge nurse stated the care plan contained no interventions for a VRS telephone number and she was unaware of a VRS system, also relying on hand gestures and head nods for assessments and medication administration, and acknowledging that written communication with the resident was poor. The SW and FSM, identified by the Administrator as potential interpreters, had only basic ASL skills, no formal ASL training, and no interpreter certification, and the SW’s work schedule did not provide coverage at all times. Reference to guidance from the National Association of the Deaf in the record review emphasized that basic sign language skills by staff do not meet the standard for a qualified interpreter, underscoring that the facility did not provide qualified auxiliary aids or services necessary to ensure effective communication with the resident.
Failure to Report Alleged Sexual Abuse Within Required Time Frames
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of sexual abuse to the State Agency and other required authorities as mandated by regulation and the facility’s own Abuse, Neglect, and Exploitation policy. A hospice RN alleged that a male resident receiving hospice care had been sexually assaulted after blood was observed on his bedding and adult brief during incontinent care. Nursing documentation shows that a CNA discovered the blood, an LVN notified hospice, and the hospice nurse subsequently approved transfer to the ER for a Sexual Assault Nurse Examiner (SANE) evaluation based on suspicion of assault. The resident involved was an elderly male admitted with hospice care, with diagnoses including senile degeneration of the brain, aphasia, a non‑traumatic brain disorder, serious mental illness, highly impaired hearing, severely impaired sight, memory problems, and severely impaired cognitive skills for daily decision making. He required substantial to maximal assistance with toileting hygiene and was always incontinent of bowel and bladder. His care plan included monitoring for signs and symptoms related to second‑degree hemorrhoids, including small amounts of blood in the stool or on toilet paper, incomplete bowel movements, a soft lump at the anal opening, and rectal itching or burning. Nursing notes document that the resident was sent to the hospital for SANE evaluation and later returned, with a nurse practitioner noting that the SANE exam found no evidence of sexual assault and that the likely source of bleeding was grade 2 hemorrhoids. Despite this, interviews revealed that the ADON was unaware whether the allegation had been reported to the State Agency, and the Administrator acknowledged being aware of the hospice nurse’s allegation of sexual assault and not reporting it. This inaction conflicted with the facility’s written policy requiring immediate investigation and reporting of all alleged violations of abuse, neglect, or exploitation to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified time frames, including within two hours when the events involve abuse or result in serious bodily injury.
Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to investigate and report an allegation of sexual abuse for one resident in accordance with its abuse, neglect, and exploitation policy and federal requirements. The resident was an elderly male admitted for hospice care with diagnoses including senile degeneration of the brain, aphasia, second-degree hemorrhoids, serious mental illness, highly impaired hearing, severely impaired sight, memory problems, and severely impaired cognitive skills for daily decision making. He required substantial to maximal assistance with toileting hygiene and was always incontinent of bowel and bladder. His care plan included monitoring for signs and symptoms related to hemorrhoids, such as blood in the stool or on toilet paper, incomplete bowel movements, a soft lump at the anal opening, and rectal itching or burning. On the date of the incident, a CNA found blood on the resident’s bedding and adult brief while providing incontinent care, and an LVN documented this finding and contacted the hospice provider, which agreed to send a nurse. Later that day, the LVN documented that the hospice nurse approved transferring the resident to the hospital for a SANE (sexual assault nurse examiner) evaluation, indicating suspicion of sexual assault. The LVN also documented that the ADON and the Administrator were notified of the hospice order to send the resident to the ER for evaluation and treatment. The resident was subsequently transferred to the hospital and later returned, and a nurse practitioner documented that the SANE exam showed no obvious external trauma and that the likely source of bleeding was grade 2 hemorrhoids. During interviews, the ADON stated that the hospice nurse had alleged the resident had been sexually assaulted and confirmed that the facility sent the resident to the hospital for rectal bleeding, where hemorrhoids were identified as the source. The ADON reported she was not aware whether the facility had reported the alleged sexual assault to the State Agency. The Administrator stated he was aware of the hospice nurse’s allegation of sexual assault and acknowledged that he had not reported the allegation nor submitted an investigation report to the State Agency. This inaction conflicted with the facility’s abuse, neglect, and exploitation policy, which required immediate investigation of any suspicion or report of abuse and reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified time frames.
Failure to Develop and Implement Comprehensive Communication Care Plan for Deaf, Non-Speaking Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address the communication needs of a deaf and mute resident. The resident was admitted with diagnoses including deaf non-speaking status, traumatic brain injury, schizoaffective disorder bipolar type, and paraplegia, and required ADL safety support. Physician orders allowed the use of “hand-talk” for communication, and the admission MDS and records indicated the resident used ASL, interpreter services, and an iPad with a visual relay service (VRS). However, the written care plan did not include specific interventions or instructions for how staff should use the resident’s ASL telephone or VRS, nor did it clearly operationalize the communication methods needed for this resident. The care plan documented that the resident had impaired communication due to being deaf and mute, refused to use a communication board, and was to use sign language, writing, or interpreter/communication devices, including interpreter services via video. The stated goal was that the resident would be able to communicate basic needs with a communication/interpreter device by a target date, and the listed interventions were limited to answering questions as needed, repeating as necessary, and generally communicating through sign language, writing, or interpreter devices. The care plan did not specify the resident’s VRS phone number, did not include instructions for setting up or using the ASL telephone or tablet, and did not identify how communication would occur when staff did not know ASL or when the social worker or food service manager, who had informal ASL skills, were unavailable. Interviews and record reviews showed that key staff were unaware of the VRS system and lacked clear guidance on communication methods. The Administrator and DON stated the resident could communicate with hand gestures, read and write, read lips, and use an iPad with a visual interpreter service, and believed the care plan was accurate. In contrast, the Ombudsman reported learning from the resident and a relative that the resident had poor reading, writing, and spelling skills, could not lip read, and that the facility had not assisted with the iPad and VRS service. CNAs and the LVN caring for the resident confirmed there were no Kardex or care plan instructions for using a phone or VRS, they did not understand ASL, and they relied on hand gestures and head nods for care and assessments. The social worker and food service manager, identified as informal interpreters, had no formal ASL training or certification and were not available around the clock. The facility’s own Comprehensive Care Plans policy required person-centered care plans with resident-specific interventions and, for non-English-speaking residents, identification of how communication would occur, but the resident’s care plan did not fully meet these requirements.
Unlabeled Water and Food Items Stored on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and labeling practices on a medication cart used for resident care. During an observation of a medication pass, an LVN was found using a medication cart that contained a covered 1‑gallon water pitcher filled with water that had no label to identify when the water was poured. In the same cart drawer, the LVN stored a clear plastic cup with a lid containing approximately 2 ounces of pudding and another similar cup containing jelly, both without labels or dates to indicate what the contents were or when they were served. The LVN reported that he had filled the water pitcher and obtained the pudding and jelly from the kitchen earlier that day and acknowledged he had not labeled them, despite being aware that professional standards required labeling with the date prepared to ensure the items were safe to serve. In an interview, the ADON confirmed that nursing staff routinely use fresh water, pudding, and jelly to assist residents with medication administration and stated that facility training, professional practice, and policy require staff to place a label on water pitchers and on pudding and jelly containers indicating the date they were prepared. The ADON explained that the absence of labels on these items created uncertainty about when they were prepared and whether they were safe to serve. Review of the facility’s Medication Administration policy showed that staff are required to keep the medication cart clean, organized, and stocked with adequate supplies, and specifically to cover and date fluids and food. The observed unlabeled water, pudding, and jelly on the medication cart were not in accordance with these professional standards and facility policy.
Persistent Urine Odor and Unsanitary Room Environment for a Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide a safe, sanitary, comfortable, and homelike environment for one resident. The resident was admitted with acute kidney failure, chronic kidney disease, muscle weakness, and a need for assistance with personal care, and had a care plan indicating incontinence related to impaired mobility and behaviors, with use of briefs. The MDS showed the resident had a BIMS score of 15, sometimes refused care 1–3 days per week, and required substantial assistance to toilet. On the survey date, surveyors noted a strong urine odor on the second-floor hallway upon exiting the elevator, which intensified near and inside the resident’s room. Inside the room, the bed was unmade, with a mattress protector and sheet that were faded yellowish/brown, and there was a strong ammonia-like urine odor; the resident stated he could not smell the odor. Later the same day, surveyors again noted a persistent urine odor in the hallway even with the resident’s door closed, and upon opening the door, the urine odor was so strong the surveyor could only remain in the room for a few minutes, despite the bed having been made. A housekeeper reported working the 12:00 pm–8:00 pm shift and cleaning the resident’s room about three times a day, with the 6:00 am–2:00 pm shift also cleaning the room once daily. The housekeeper stated the resident’s mattress had been changed in an attempt to address the odor, but this did not help, and that staff frequently complained about the smell. The Maintenance Director acknowledged the room had smelled that way “for a while” and that cleaning had not resolved the issue; he stated the room floors could not be stripped and that they continued to try to clean the room. The Administrator reported ongoing issues with the resident not getting out of bed to use the toilet and refusing to use the briefs provided, contributing to the persistent urine odor and unsanitary room conditions.
Failure to Maintain Safe and Adequate Lighting and Electrical Service in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not maintaining adequate and functional lighting and electrical service in three resident rooms. In rooms #10, #11, and #12, over‑bed lights were nonfunctional and there were additional electrical issues affecting other electronics. The Maintenance Supervisor reported that he had replaced outlets in these rooms and identified a wiring problem, particularly in one room, but stated he did not have the equipment to fix it. He also stated that the circuit breaker for the affected circuit would not stay on, so he turned it off as a precaution, which also disabled the over‑bed lights, and that the building had old wiring. One male resident in room #11, with diagnoses including major depressive disorder, schizoaffective disorder bipolar type, traumatic brain injury, and PTSD, and care planned for PTSD, traumatic brain injury, and risk for falls, reported that there had been no electricity in his room since about a week before Halloween. He stated that the room lights, television, and over‑bed lights did not work, and that he almost fell going to the bathroom because the room was dark. During observation, the room was dark except for light from the hallway, and attempts by the investigator to turn on the main room light and over‑bed lights were unsuccessful; the resident’s television also did not work when he attempted to turn it on. Another male resident in room #12, with left‑sided hemiplegia, type 2 diabetes, major depressive disorder, and PTSD, and care planned for PTSD, major depressive disorder, fall precautions due to hemiplegia, and mild cognitive impairment, was observed in a dark room partially lit by the hallway while watching television. He reported that his television would short out and stop working and that he had been told the facility was working on the problem. The over‑bed light in his room did not work when tested. A female resident in room #10, with hypertension, anxiety disorder, and age‑related physical disability, care planned for falls, gait/balance problems, and falls related to seizures, reported that her bathroom light sometimes did not work. She stated she had fallen when trying to get back into bed after using the bathroom and once when the bathroom light did not work, though she was not injured. Observation showed the main room light only partially illuminated the room and the over‑bed lights did not function. The facility’s own policy required maintaining adequate and comfortable lighting levels in all areas and periodic rounds by the Maintenance Director to ensure functioning lights.
Failure to Protect Residents From Verbal and Physical Abuse by an LVN
Penalty
Summary
The facility failed to protect three residents from abuse by LVN B, in violation of its abuse, neglect, and exploitation policy. One resident, an older female with anxiety disorder, hypertensive heart disease, and major depressive disorder, had a BIMS score of 13 indicating no cognitive impairment and was care planned for depression, anxiety, and fall precautions. She reported that LVN B was not nice, acted like a bully, and that the situation involving her money "went too far," stating it was none of the nurse’s business what she did with her money. Staff interviews indicated that LVN B questioned this resident about giving $200 to another resident and continued to antagonize her about the money. Another resident, a 66-year-old male with end stage renal disease, type 2 diabetes, and anxiety disorder, had a BIMS score of 15 indicating he was cognitively intact and was care planned for dialysis and right below-knee amputation. He reported that he and LVN B were "going back and forth" verbally, and that she hit him, pushed his wheelchair, and pushed him in the chest in front of other workers, after which he hit her back. Multiple staff interviews (MA C and CNA D) described that this resident and another were playing chess and listening to the television when LVN B repeatedly told him to turn the television down, unplugged the television when he did not comply to her satisfaction, told him to go back to his room, blocked his access to the nurses’ station and the posted Administrator’s phone number by using a medication cart, and grabbed his arm/wrist and held it against his chest. CNA D stated the resident said it hurt and sounded like he was about to cry while asking if she was going to let him go. A third resident, an older male with type 2 diabetes, COPD, schizophrenia, and anxiety disorder, had a BIMS score of 5 indicating severe cognitive impairment but was able to be interviewed and recall the incident with LVN B. He stated he was angry about what the nurse did, described her as very disrespectful with a bad attitude, and said he had signed himself out and wanted to listen to his radio on the porch, but she would not enter the code to allow him to go outside. The Administrator reported that another staff member (MA E) recorded an incident in which LVN B told this resident he could not go outside on the front porch to listen to music after he had signed himself out, and that during the exchange the resident told LVN B to shut up and she told him to shut up, further telling him he needed to go back upstairs, that he did not live on that unit, and that he should go upstairs to "disrespect" the nurses there. These events, as reported by residents and staff, demonstrate that the facility did not ensure residents’ right to be free from verbal and physical abuse by staff.
Uncertified Staff Administered Medications Without Proper Credentials
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and valid certifications required to provide care and administer medications to residents. Specifically, Staff Member A worked a total of 88 shifts administering medications and performing duties as a Medication Aide (MA) without holding a valid MA certificate or CNA certification during the period in question. Staff Member A was listed incorrectly as an LVN on the staff roster, and her Graduate Vocational Nurse (GVN) permit had expired. Despite this, she continued to work under the supervision of an RN, and her credentials were not properly verified or maintained by the facility's Human Resources Director (HRD) or Director of Nursing (DON). The facility's own policy required verification of licensure and certification, but this was not followed, and Staff Member A was allowed to work without the necessary credentials. Record reviews confirmed that Staff Member A signed as a CMA on facility training and administered medications to residents, although there were no documented hospitalizations, harm, or negative outcomes related to her actions. Interviews with the DON, HRD, and Administrator revealed a lack of awareness and oversight regarding Staff Member A's expired or missing certifications. The DON acknowledged that Staff Member A was not an MA and had not taken the MA test, and the HRD confirmed that Staff Member A's GVN was expired upon hire. The Administrator was unaware of the lack of a current MA certificate. The facility's failure to ensure proper licensure and certification for staff directly led to this deficiency.
Failure to Document Physician Review of Pharmacy-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that the attending physician documented in the medical record that identified medication regimen irregularities had been reviewed and what, if any, actions were taken to address them for one resident. Specifically, pharmacy recommendations regarding the resident's medication regimen in August and September were communicated to the facility, but there was no documentation in the resident's progress notes indicating that a provider had reviewed or responded to these recommendations. The pharmacist reported sending communications about the resident's medications and noted a lack of direct response from the provider, with the process defaulting to continuation of the current regimen in the absence of a response. The ADON stated that her process was to forward pharmacy reviews to providers and await a response, but if no response was received, she did not follow up and the medication regimen continued as ordered. The physician overseeing care was unaware of the unanswered pharmacy recommendations and expected immediate responses to such communications. Review of facility policy indicated that the pharmacist, in collaboration with the facility and medical director, is responsible for developing and revising procedures for pharmaceutical services, but the required documentation and follow-up were not completed in this case. The resident involved had a history of intentional self-harm and chronic pain, was taking opioid medication, and had intact cognition.
Failure to Maintain Safe and Homelike Bathroom Environment for Two Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents. For one resident with severe cognitive impairment and multiple medical conditions, the interior-facing bathroom door was observed to be unpainted on the lower third and had multiple scratch marks. For another resident with moderate cognitive function and significant medical diagnoses, the bathroom entrance had a 3-inch rust area on the left door post, and the toilet was not secured to the floor, allowing it to move during use. Both residents were observed using these bathrooms, and one resident reported that the rusted area had been visible for a month and expressed a desire for the toilet to be repaired. During a joint observation with the Administrator and Maintenance Director, it was confirmed that the bathroom door, door post, and toilet required repairs. The facility's Preventative Maintenance Program policy was reviewed and indicated that a program should be in place to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. However, the observed conditions in the bathrooms used by these two residents demonstrated a failure to maintain such an environment as required by policy.
Deficiencies in Kitchen Cleanliness and Maintenance
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's main kitchen and associated areas regarding the storage, preparation, distribution, and serving of food in accordance with professional standards. Specifically, six ceiling tiles in the main kitchen were found to be dirty and stained, and a fluorescent light bulb was missing from an overhead fixture. Additionally, a ceiling air vent in the dish room was noted to have rust on the vent blades. In the employee bathroom located in the main kitchen area, there was a section of missing floor molding and a wall penetration measuring approximately three inches in diameter. Interviews with the Food Service Director, Administrator, and Maintenance Director confirmed awareness of these issues, with each acknowledging that such conditions could affect the cleanliness of the kitchen. Review of facility policy and the U.S. FDA Food Code highlighted the requirement for food service areas and equipment to be maintained in a clean and sanitary manner, with non-food-contact surfaces kept free of dust, dirt, and other debris. The observed failures to maintain these standards were documented during the survey.
Incomplete Medication Administration Record Documentation
Penalty
Summary
A deficiency was identified when a resident's Medication Administration Record (MAR) for July 2025 contained blank spaces on July 5, 2025, instead of the required documentation for medication administration and monitoring. The resident, who had diagnoses including essential primary hypertension, generalized anxiety disorder, and type 2 diabetes mellitus, was prescribed multiple medications and required regular monitoring as outlined in their care plan and physician orders. Review of the MAR showed that documentation was missing for the administration of antihypertensive and antianxiety medications, pain assessment, and blood glucose checks on the specified date. Additionally, there were no progress notes for that day regarding medication administration. Interviews with facility staff confirmed that the nurse assigned to the resident on the date in question did not document the administration or refusal of medications and monitoring. The Director of Nursing acknowledged the blank spaces and stated that it was expected for nursing staff to document all medication administration or refusals. The facility's policy required complete, accurate, and timely documentation in each resident's medical record, which was not followed in this instance.
Improper Disposal of Garbage Due to Open Dumpster Door
Penalty
Summary
Surveyors observed that one of two outdoor garbage dumpsters had a sliding door measuring approximately 4x4 feet left open, with the bin full of garbage bags. This observation was made in the presence of the Food Service Director, who acknowledged awareness that the garbage lid should have been closed for pest control prevention. The Administrator, when interviewed, stated he was not aware of the specific requirement to keep garbage lids closed but agreed it would help maintain pest control. Review of facility policy and federal food code confirmed that all garbage and refuse containers must be kept covered with tight-fitting lids or doors when stored or not in continuous use.
Unsecured Maintenance and Housekeeping Office with Hazardous Items
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment by leaving the Maintenance and Housekeeping Office door ajar and unattended. The office, which contained tools and cleaning equipment, was observed open with no staff present. The office was located on the second floor, near resident rooms and adjacent to the nurses' desk. Housekeeper E was seen in the hallway between the office and a resident's room, but not inside the office itself. Both Housekeeper E and the Maintenance Director confirmed that the office was usually kept locked due to the presence of potentially unsafe items for residents. The Maintenance Director admitted to leaving the office open and unattended, believing it was safe because Housekeeper E was nearby in the hallway. The DON stated that her expectation was for the office to be secured at all times when not in use by staff, as it contained items that could be unsafe for residents. Review of the facility's policy confirmed that hazardous areas, devices, and equipment should be identified and addressed to ensure resident safety.
Resident Left Unattended in Urine Due to Delayed Incontinent Care
Penalty
Summary
A deficiency occurred when a resident with moderate intellectual disability and anxiety disorder, who was assessed as continent of bowel and bladder but requiring cues to use the toilet, was found sitting in urine in a dining room chair. The incident took place in the evening, after the resident had been assisted to the dining room for her meal and had not been attended to for an extended period. Family members discovered the resident in this condition, with a puddle of urine on the floor and a wet brief around her ankle, and reported their concerns to staff present in the room. The male RN on duty at the time was present in the dining room, working on a computer, but did not notice or address the resident's condition until the family brought it to his attention. The CNA assigned to the resident stated she had last changed the resident before dinner and had not checked on her again until after the family reported the incident. The CNA explained that her routine was to perform check and change room by room after dinner, and the dining room was at the end of her route, which contributed to the delay in care. The facility's policy requires that residents unable to perform activities of daily living independently receive necessary assistance with hygiene and toileting. Despite this, the resident was left unattended and wet for an undetermined period, contrary to the facility's expectations and policy. The DON confirmed that staff are expected to immediately address such situations, especially when not engaged in direct resident care.
Incomplete Documentation of Wound Care in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were maintained in accordance with accepted professional standards and practices. Specifically, the Treatment Administration Record (TAR) for a resident with multiple chronic conditions, including chronic heart failure, diabetes with neuropathy, lymphedema, and peripheral vascular disease, contained blanks on four out of fourteen designated wound care treatment days. These blanks indicated that the completion or refusal of prescribed wound care was not accurately documented for the specified dates. The resident was prescribed wound care to be performed twice weekly and as needed, with clear orders for cleansing, application of medication, and dressing changes. Observations and interviews revealed that the resident's dressings were not always changed as scheduled, and the resident herself reported that wound care was not consistently provided on the assigned days. The nurse responsible for treatments acknowledged that documentation was sometimes missed, either because she was not present or because she forgot to document after providing care. In cases where the resident refused care, this was also not consistently recorded on the TAR as required. The Director of Nursing confirmed the presence of documentation gaps and stated that refusals or completed treatments should have been properly recorded on the TAR. Facility policy required detailed documentation of wound care, including the type of care given, date and time, assessment data, and any refusals with reasons. The lack of accurate and complete documentation on the TAR made it difficult to determine whether wound care was provided or refused on the specified dates.
Unattended Medication Cart Left Unlocked in Resident Area
Penalty
Summary
A deficiency was identified when a medication cart (Med Cart 1) was observed unlocked and unattended in a common area near the nurses' station, across from the elevator on the second floor. The cart contained both over-the-counter and resident medications. During the time the cart was left unlocked, multiple residents, including one in a wheelchair who made physical contact with the cart, were present in the vicinity. Staff members, including a CNA and a housekeeper, were also nearby, and several residents were observed walking around the area. The nurse assigned to the cart confirmed that it was not supposed to be left unlocked and acknowledged the presence of mobile and ambulatory residents in the halls. Interviews with facility leadership, including the ADON and DON, confirmed that the facility's policy requires medication carts to be locked when unattended, and that the responsibility for securing the cart lies with the assigned nurse or medication aide. Both leaders emphasized the importance of keeping medication carts locked due to the presence of residents who may not be fully alert and oriented, and the potential for unauthorized access to medications and supplies. Review of the facility's policy corroborated these expectations, stating that all drugs and biologicals must be stored in locked compartments.
Failure to Assist Resident in Obtaining Dental Services After Loss of Dentures
Penalty
Summary
The facility failed to assist a resident in obtaining dental services after her top dentures were reported missing. The resident, who had diagnoses including cerebral infarction, kidney disease, and dementia, was admitted with a top denture as documented on her inventory sheet. Despite an email from the resident's family representative notifying facility leadership of the missing dentures, there was no evidence that the facility took steps to assist the resident in obtaining replacement dentures or dental care. The resident's care plan noted a risk for oral health problems and the need to coordinate dental care, but did not mention the missing dentures. Interviews with staff, including the DON and Administrator, revealed they were unaware of the missing dentures, and both expressed concern about the risk of choking if the resident continued to eat without them. Observation confirmed the resident had no natural upper teeth, and interviews with the resident and staff corroborated that the dentures were lost while in the facility's care. The facility's policy required protection of dentures from loss or damage, but this was not followed. The resident continued to eat a regular diet and gained weight during the period, but her oral health needs were not addressed as required by facility policy and care planning.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs and preferences of three residents by not ensuring their call lights were within reach. Resident #3, a female with severe cognitive impairment and multiple diagnoses including anoxic brain damage and schizoaffective disorder, was found with her call light on the floor approximately four feet away from her bed. Despite her care plan emphasizing dignity and respect, the call light was not accessible, which was confirmed by staff interviews. Resident #6, a male with no cognitive impairment but with a history of lymphedema and schizoaffective disorder, was observed with his call light on the floor behind the headboard of his bed while he was eating lunch. His care plan required the call light to be within reach to prevent falls and ensure prompt assistance, yet it was not accessible, as confirmed by the resident himself. Resident #8, a male with severe cognitive impairment, Alzheimer's disease, and legal blindness, was found with his call light on the floor under a wheelchair, five feet away from his bed. His care plan also required the call light to be within reach due to his risk of falls and need for assistance. Staff interviews confirmed the expectation for call lights to be accessible, but this was not adhered to, leading to the deficiency.
Privacy Deficiency During Incontinent Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during incontinent care, as observed by a surveyor. The resident, a female with severe cognitive impairment and multiple diagnoses including anoxic brain damage and schizoaffective disorder, was dependent on staff for personal care. During an observation, it was noted that the privacy curtain for the resident's bed was missing, which compromised her privacy during care. Interviews with the CNAs involved in the care revealed that they were aware of the missing privacy curtain and attempted to provide privacy by closing the curtains for the other beds in the room. However, the absence of a privacy curtain for the resident's bed meant that her privacy was not fully protected if someone entered the room. The Housekeeping Director acknowledged the missing curtain and stated that it had been down for about a month, although a work order indicated it had been missing since 2022. The facility's policies on resident rights and dignity emphasize the importance of privacy during personal care. Interviews with the Administrator and DON confirmed that staff are trained to use privacy curtains to maintain resident dignity and privacy. Despite this, the lack of a privacy curtain for the resident's bed was not addressed in a timely manner, leading to a deficiency in maintaining the resident's right to privacy during care.
Inaccurate Documentation of Wound Care
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, specifically regarding the administration of bilateral wound treatments. The treatment administration records (TAR) for the resident did not accurately reflect the administration of wound care on two specific dates. This discrepancy was identified during a review of the resident's records, which showed that the TAR was not initialed by a nurse as completed on those dates, leading to a lack of documentation for the treatments that were supposed to be administered. The resident in question was an elderly female with multiple diagnoses, including congestive heart failure, type 2 diabetes, bipolar disorder, and lymphedema. She was dependent on staff for various activities of daily living and had a history of rejecting care. The resident's care plan included specific instructions for wound care due to her risk for pressure injuries and existing vascular wounds on her lower legs. Despite these detailed care plans, the facility's records did not consistently document the completion of the required wound treatments. Interviews with the nursing staff revealed a lack of proper documentation practices. The Wound Care LVN and RN C were involved in the resident's care but failed to document the treatments accurately in the TAR. The Wound Care LVN admitted to not signing off on the TAR for one of the dates and relied on personal notes instead of official documentation. RN C also did not document the wound care he provided, assuming the Wound Care LVN would handle it. This lack of documentation could potentially place residents at risk of not receiving appropriate care, as it obscures whether treatments were administered as prescribed.
Failure to Notify Legal Guardian of Resident's Transfer
Penalty
Summary
The facility failed to adequately prepare and inform the legal guardian of a resident for the resident's transfer to a hospital, resulting in a deficiency in discharge rights. The resident, a male with dementia and schizoaffective disorder, was admitted to the facility with a legal guardian appointed due to his incapacitated status. Despite this, there was no written discharge or transfer notice provided to the legal guardian when the resident was transferred to the hospital. The legal guardian was unaware of the resident's transfer and was unable to follow up, leading to a missing person's report being filed. The facility assumed that the hospital would communicate with the legal guardian regarding the resident's discharge and subsequent placement at another nursing home. However, there was no documentation of these communications or actions. The resident was later found at a different nursing home, claiming to be his own responsible party, with no mention of a legal guardian. The facility's policy required notice of transfer to be provided to the resident and representative, but this was not adhered to, resulting in a lack of preparation and orientation for the resident's discharge.
Failure to Maintain Oxygen Humidifier Bottles
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required oxygen therapy. Resident #4, a male with acute kidney failure, respiratory failure, and atrial fibrillation, was observed with an empty oxygen humidifier bottle on his oxygen concentrator. The bottle was dated 5/12/24, indicating it had not been changed as required. Resident #4 had a BIMS score of 15, indicating intact cognition, and his physician's orders included oxygen at 2 liters per nasal cannula as needed for shortness of breath. Similarly, Resident #56, a male with respiratory failure, cirrhosis of the liver, and depression, was also found with an empty humidifier bottle on his oxygen concentrator, dated 5/12/24. Resident #56 had a BIMS score of 7, indicating severe cognitive impairment. Interviews with RN C and the DON revealed that the night shift was responsible for changing and dating the oxygen tubing and humidifier bottles weekly. However, the DON was unaware of why the bottles were not changed and acknowledged the risk of dry nasal passages for the residents due to the empty humidifier bottles.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During an observation, it was noted that a resident's room had a broken electrical outlet with an open electrical connection and no outlet cover. Additionally, another resident's room had a roof leak that resulted in a puddle of water on the floor near the room entrance. In the hallway, a section of floor paneling was missing, and a ceiling panel had water stain marks. Interviews revealed that the Maintenance Director had inadvertently broken the electrical outlet while moving a bed and was unaware of the roof leak until the day of the observation. The Administrator also stated that she had just become aware of the roof leakage. The facility's maintenance policy, dated 2001, indicated that maintenance services should be provided to all areas of the building, grounds, and equipment, following established safety regulations to ensure safety and well-being.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a necessary accommodation for their needs and preferences. Resident #46, a female with schizoaffective disorder, dysphagia, and unsteadiness on her feet, was found to have her call light wrapped on the call light box on the wall, making it inaccessible. Her care plan specifically required the call light to be within reach due to her risk of injury. During an interview, Resident #46 expressed that the call light was often moved away from her, preventing her from calling for assistance. The assigned CNA admitted to forgetting to reposition the call light after providing care. Similarly, Resident #55, a male with muscle weakness, insomnia, and Type II Diabetes, also had his call light out of reach on the nightstand. His care plan also required the call light to be accessible due to his risk of injury. Resident #55 reported that the call light was frequently moved away from him. The CNA responsible for his care confirmed that the call light was usually kept on the nightstand, which was not within the resident's reach. The DON acknowledged that call lights should be within arm's length of all residents and that the lack of accessibility could lead to falls if residents needed assistance.
Failure to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents. In the case of one resident, barrels containing soiled linens and trash were improperly stored in the shower area of the resident's restroom. This was confirmed by the Director of Housekeeping, who acknowledged the issue and indicated that staff had been instructed not to store these items in such a manner. For another resident, the shower chair and the floor of the shower area in the restroom were found to be soiled with a dark brown substance resembling mud or feces. This observation was confirmed by the Assistant Director of Nursing (ADON), who agreed that the condition of the shower area was unacceptable. The facility's policy on resident rights emphasizes the importance of providing a safe, clean, and comfortable environment, which was not upheld in these instances.
Resident Access to Electronic Cigarette in Room
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by allowing a resident to have access to an electronic cigarette. The resident, a male with a history of muscle weakness, insomnia, and Type II Diabetes, was observed smoking an electronic cigarette in his room, despite being assessed as a supervised smoker. His care plan indicated that he should be instructed on smoking locations, yet he stated that he makes his own rules and smokes in his room. Interviews with facility staff revealed that the resident was sometimes non-compliant with the supervision requirement. The assigned nurse confirmed the resident's need for supervision while smoking, and the Administrator acknowledged the potential fire hazard posed by the resident smoking in his room. The facility's policy on safety and supervision of residents emphasized the use of dedicated smoking areas, which was not adhered to in this case.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was not given a psychotropic drug unless it was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was prescribed Xanax, a psychotropic drug, for anxiety on a PRN basis for an indefinite period, which is against the facility's policy that limits PRN orders for psychotropic medications to 14 days. The resident, a female with a moderately impaired cognition as indicated by a BIMS score of 12, was admitted with diagnoses including congestive heart failure, chronic pain syndrome, and muscle weakness. The Director of Nursing (DON) confirmed the oversight during an interview, acknowledging that the order for Xanax should have been limited to 14 days. The DON noted that the Assistant Director of Nursing (ADON) was responsible for overseeing such tasks daily, but the monitoring was done randomly, leading to this oversight. The facility's policy on psychotropic medication use, revised in July 2022, clearly states the 14-day limit for PRN orders, which was not adhered to in this case.
Deficient Food Storage Practices in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of food items in a resident's personal refrigerator, which could lead to foodborne illness. During an observation, it was found that the refrigerator in a resident's room contained open and undated lunch meat. Interviews with a CNA and the DON confirmed that the refrigerator contained unlabeled and undated perishable food items. The facility's policy requires that perishable foods brought by family or visitors be labeled and dated, and the night shift nurses are responsible for monitoring this. However, this monitoring was not being conducted at the time of the survey.
Improper Garbage Storage Leading to Pest Risk
Penalty
Summary
The facility failed to maintain the garbage storage area in a manner that prevents the harborage of pests. On two separate occasions, observations were made with the Dietary Director where one of the two garbage bins used by the facility had a side-lid covering that was left open, exposing bags of garbage. The first observation occurred on June 11, 2024, at 11:15 a.m., and the second on June 12, 2024, at 11:00 a.m. During an interview on June 12, 2024, the Dietary Director acknowledged awareness that the garbage bin lids must remain closed at all times to prevent pest problems. Additionally, the Administrator confirmed understanding of the regulation requiring garbage bins to remain closed to prevent pest issues. A review of the facility's policy on Food-Related Garbage and Refuse Disposal revealed that all garbage and refuse containers must be kept covered with a tight-fitted lid when stored and not in continuous use.
Failure to Provide Adequate Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide adequate foot care and access to podiatry services for a resident, leading to discomfort and potential health risks. The resident, a female with severe cognitive impairment and medically complex conditions, was at risk of developing pressure injuries. Despite having orders to see a podiatrist, the resident's toenails were long and overgrown, causing a sore on her toe. The hospital RN noted that the toenails needed trimming and filing, but the hospital staff was not permitted to perform this procedure, and the resident was not expected to stay long enough to see the hospital's podiatrist. The resident's family member had requested podiatry services months prior, but the resident was not seen during the podiatrist's visits to the facility. The DON stated that nurses were responsible for trimming residents' nails weekly, but there was no documentation of recent care for the resident's toenails. The Treatment Nurse admitted to possibly forgetting to document the last nail trimming, and the ADON found no records of the resident ever being seen by a podiatrist. The lack of documentation and follow-up on podiatry services resulted in missed care, increasing the risk of infection or pain for the resident.
Failure to Implement Comprehensive Care Plan Leads to Resident's Suicide Attempt
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. The resident, a male with dementia, depression, and anxiety, was admitted with a BIMS score indicating mild cognitive impairment. His care plan required monitoring for changes in cognitive function and psychosocial well-being, including fear of being alone, which was not adequately followed by the staff. On a specific date, an LVN failed to document or report the resident's expressed fear of being alone, as required by the care plan. The following day, the resident attempted suicide by trying to strangle himself with a shirt. This incident highlighted the failure to monitor and report significant changes in the resident's mental state, which was a critical component of his care plan. Interviews with facility staff, including the Psych NP and MD, revealed that there was no prior indication or report of the resident being at risk for self-harm. The facility's policy required comprehensive, person-centered care plans with measurable objectives, which were not effectively implemented in this case, leading to the identification of Immediate Jeopardy.
Failure to Provide Appropriate Mental Health Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with a mental disorder and psychosocial adjustment difficulties. The resident, a male with dementia, depression, and anxiety, displayed increased signs of fear and requested staff presence due to feeling scared. Despite these signs, Licensed Vocational Nurse (LVN) A did not implement interventions or arrange for psychiatric services promptly. This inaction led to the resident attempting suicide the following day by attempting to strangle himself with a shirt. The resident's medical records indicated a history of moderately severe depression and cognitive impairment. His care plan included monitoring for changes in cognitive function and mood, as well as consulting with psychiatric services. However, the facility's records showed that behavior monitoring was not conducted according to the care plan. A psychiatric follow-up note prior to the incident indicated increased anxiety due to a recent altercation, but no immediate risk for self-harm was identified. Despite this, the resident expressed fear and a desire for company, which was not adequately addressed by the staff. Interviews with facility staff revealed a lack of communication and adherence to the care plan. The psychiatric nurse practitioner and medical director were not informed of the resident's expressed fear or suicidal ideation. The facility's policy required comprehensive, person-centered care plans, but the failure to implement these plans and monitor the resident's condition contributed to the incident. This deficiency was identified as an Immediate Jeopardy situation, indicating a serious threat to the resident's health and safety.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to adequately monitor residents who were prescribed psychotropic medications for side effects and effectiveness, as required by their care plans. This deficiency was observed in six residents who were reviewed for medication management. The facility did not have orders for monitoring target behavior symptoms or side effects for the psychotropic medications prescribed to these residents. This lack of monitoring could potentially place residents at risk for adverse consequences related to the use of these medications. Resident #1, a male with dementia, depression, and anxiety, was not monitored for side effects or behaviors related to his prescribed antidepressant and antianxiety medications. His care plan required monitoring for safety and documenting occurrences of target behavior symptoms, but no such orders were found. Similarly, Resident #2, with severe cognitive impairment and depression, was not monitored for side effects or effectiveness of his prescribed antianxiety, antidepressant, and anticonvulsant medications, despite care plan requirements. Other residents, including Resident #3 with mild cognitive impairment, Resident #4 with dementia and major depressive disorder, Resident #5 with expressive language disorder, and Resident #6 with major depressive disorder, were also not monitored for side effects or effectiveness of their psychotropic medications. Interviews with facility staff, including a Psych NP and an MD, revealed that while staff believed they were adequately monitoring residents, there were no specific orders or documentation to support this. The facility's policy on behavioral monitoring required compliance with regulatory requirements, but this was not reflected in the monitoring practices observed.
Failure to Report Resident's Suicide Attempt
Penalty
Summary
The facility failed to report an incident involving a resident's attempted suicide to the State Survey Agency within the required timeframe. The resident, a male with dementia, depression, and anxiety, was admitted to the facility and later discharged to an acute care hospital following the suicide attempt. The resident had a history of cognitive impairment and moderately severe depression, as indicated by his BIMS and PHQ9 scores. Despite these indicators, the facility did not report the incident as required by federal and state regulations. The incident occurred when the resident attempted suicide by using a shirt fashioned as a noose to cut off his airflow. This was documented in a progress note by an LVN, and the resident was subsequently admitted to a local hospital. Interviews with hospital staff confirmed the suicide attempt. However, the facility's administrator did not report the incident, believing it did not qualify as a reportable event based on her review of the reporting pathway and previous facility procedures. The facility's policies on abuse, neglect, and exploitation prevention, as well as recognizing signs of abuse or neglect, were not followed in this case. The policies clearly state that incidents involving suicidal ideation should be reported promptly. Additionally, guidance from the HHSC Long-Term Care Regulatory Provider Letter outlines the requirement to report such incidents immediately, but the facility failed to comply with these guidelines, resulting in a deficiency.
Failure to Investigate Resident's Suicide Attempt
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident involving a resident who attempted suicide. The resident, a male with dementia, depression, and anxiety, was admitted to the facility and later discharged to an acute care hospital. The resident had a history of moderately severe depression and expressed suicidal ideation. On the date of the incident, the resident attempted suicide by using a shirt fashioned as a noose. Despite this serious event, there was no evidence of a thorough investigation or documentation of the incident in the facility's records. Interviews with facility staff revealed inconsistencies in the reporting of the incident. The administrator was informed of the incident by a nurse, but discrepancies in the report led to the decision not to investigate further. The charge nurse who responded to the incident did not observe any physical signs of a suicide attempt on the resident, which contributed to the lack of investigation. However, the local hospital confirmed the resident's admission for a suicide attempt, and the resident himself confirmed the attempt. The facility's policies require the identification, investigation, and reporting of all possible incidents of abuse, neglect, or mistreatment. Despite these policies, the administrator chose not to report the incident, citing previous procedures followed before her employment. This decision was made without a thorough investigation, potentially placing residents at risk of incidents not being properly addressed.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 44% error rate based on 11 errors out of 25 opportunities. This deficiency involved a resident who did not receive their medications as scheduled. The medications, which included treatments for high blood pressure, mood disorders, and other conditions, were administered over an hour and a half late. This delay in administration could potentially affect the therapeutic outcomes for the resident. The resident involved was a male with a history of paranoid schizophrenia, atherosclerotic heart disease, peripheral vascular disease, localized edema, and constipation. He was cognitively intact, as indicated by a BIMS score of 15. The medications scheduled for 7:00 a.m. included Amlodipine, Buspirone, Calcium-Vitamin D, Clonidine, Docusate Sodium, Divalproex Sodium, Furosemide, Metoprolol Tartrate, a multivitamin, a sodium supplement, and Spironolactone. These medications were administered late, which was confirmed by the CMA responsible for the administration. The CMA reported starting her shift at 6:00 a.m. and began passing medications at 6:30 a.m. daily. Due to the number of residents and the schedule, she consistently administered medications late, particularly on F-hall. Although she reported the issue to shift nurses, she did not inform the ADONs, the prior DON, or the administrator. The facility's policies did not address timeliness in medication administration, and the MD consulted did not express concerns about the side effects or interactions due to the delay.
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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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