San Antonio West Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 636 Cupples Rd, San Antonio, Texas 78237
- CMS Provider Number
- 675002
- Inspections on file
- 53
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 40 (1 serious)
Citation history
Health deficiencies cited at San Antonio West Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain accurate clinical records for several residents receiving antihypertensive medications with specific BP and pulse parameters. For multiple residents with vascular dementia, CHF, hypertensive heart disease, and stroke history, the MARs showed blood pressure medications as administered even when recorded vital signs were below ordered hold parameters, and there were no corresponding nursing notes explaining the discrepancies. Staff interviews indicated that CMAs and LVNs report following parameters and sometimes mis-clicking in the electronic MAR, leading to incorrect documentation, while the DON acknowledged there was no process to verify whether medications were actually given or held when vitals were out of range, despite a policy requiring vital sign checks and holding medications per parameters.
Two cognitively impaired residents on a memory care unit were involved in an incident in which one was found in another’s room, in that resident’s bed, nude from the waist down and covered with a blanket, while the other sat across the room. Nursing staff assessed both residents, redressed and redirected the disrobed resident, and documented the event, but did not promptly notify either resident’s representative or physician, despite care plan and policy requirements to inform family and consult the MD for changes or concerns. Interviews with the residents’ representatives, nursing staff, hospice RN, and leadership confirmed that the representatives and physicians were not informed at the time of the incident, and that leadership assumed, without verification, that notifications had been made.
Two cognitively impaired residents in a memory care unit were involved in separate incidents, including one where a female resident with Alzheimer’s disease and on hospice was found partially disrobed in a male resident’s room with the door closed, and another where the male resident with severe dementia verbally claimed control over her, causing her distress. Nursing staff and the ADON became aware of these events, documented them, and reported at least one incident internally to leadership, but the Administrator and DON did not report the allegations to the state agency or APS as required. Facility policy mandated immediate investigation and timely external reporting of all alleged abuse, neglect, or exploitation, yet no such reports were found in the state database for the relevant period, and leadership stated they did not consider the events to be suspicions of abuse.
The facility failed to investigate and report an incident in which a cognitively impaired, hospice-enrolled resident in the memory care unit was found nude from the waist down on the bed in another cognitively impaired male resident’s room, with the door closed and the male resident fully clothed and seated on his walker. Nursing staff documented the event, assessed both residents with no injuries noted, dressed and redirected the disrobed resident, and reported the situation to supervisory staff. The ADON stated she informed the DON and the Administrator, but leadership later acknowledged they did not treat the event as a suspicion of abuse, neglect, or exploitation, viewing it instead as typical wandering and disrobing behavior. Consequently, the facility did not conduct or document a thorough abuse/neglect investigation, did not implement protective measures during an investigation, and did not submit an investigation summary to the State Survey Agency within the required timeframe.
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with dementia in the memory care unit, specifically omitting individualized interventions for one resident’s unwanted, focused attention and verbally aggressive behavior toward another resident. Although staff and a representative reported ongoing incidents where one resident scolded, cursed at, and claimed control over the other, causing distress and requiring staff redirection, these behaviors and interventions were not reflected in either resident’s care plan. Existing care plans contained only generic behavior documentation directives and did not include measurable, resident-specific objectives or timeframes, contrary to facility policy and expectations stated by the Administrator and DON.
A resident with a history of falls, hemiparesis after stroke, type II diabetes, urinary incontinence, and severe cognitive impairment experienced a fall and had a care plan intervention for labs and a UA to be collected afterward. An LVN documented that an NP ordered both a CBC and UA as part of the post-fall evaluation, but only the CBC was coordinated and completed; no UA order appeared in the physician’s orders, and no UA was obtained. In interviews, the NP stated it would be reasonable for her to order a CBC and UA to assess for infection and possible cause of falls, while the LVN stated she believed the NP only ordered a CBC and that the UA would be contingent on UTI symptoms. The DON and Administrator stated that nurses are expected to implement prescribers’ orders and that the LVN was responsible for coordinating the UA but did not, potentially denying prescribers needed lab information.
A CNA opened a room door during personal care, exposing a cognitively impaired, fully dependent resident who was lying in the bed closest to the door wearing only a brief and connected to a G-tube. The privacy curtain had been pulled but did not cover the foot of the bed, leaving the resident visible to anyone passing by while the CNA sought assistance with turning the resident, who was stiffer than usual and had hemiplegia. The DON confirmed staff are expected to ensure privacy during care and that exposing a resident in this manner violates privacy, contrary to facility policy requiring protection of bodily privacy during personal care and treatment.
A resident with paranoid schizophrenia and anxiety, who required substantial assistance with personal hygiene and had a physician’s order for podiatry care, was not placed on the facility’s podiatry schedule and had not seen a podiatrist since admission. Surveyors observed toenails about 1/2 inch past the nailbeds with very thick great toenails; the resident reported needing them cut and that a CNA had been unable to clip them due to thickness. An LVN acknowledged the long, thick toenails but had not previously noted or documented the need for referral, and the DON stated that long toenails were not documented on weekly skin sheets and that staff were expected to verbally notify the social worker instead. The social worker confirmed the resident was not on the recent podiatry list, despite a facility policy requiring staff to refer identified foot care needs so the social worker could arrange podiatry services.
A resident with severe cognitive impairment, hemiplegia, and a G-tube was on Enhanced Barrier Precautions (EBP) requiring staff to don gown and gloves for high-contact personal care. An observed CNA exited the resident’s room after providing peri-care without wearing a gown, mask, or gloves, despite an EBP sign on the door instructing use of PPE. The CNA reported there was no PPE in the room or nearby caddies and admitted she did not notify nursing staff or seek PPE from other areas. Subsequent observations showed PPE was available in the unit supply closet, and interviews with HR/central supply, the ADON (infection preventionist), and the DON confirmed that PPE was ordered weekly, stored on the hall, and that floor staff and resident ambassadors were responsible for restocking door caddies for residents on EBP, in accordance with the facility’s written EBP policy.
A resident with psychiatric diagnoses but intact cognition, who had been evaluated as safe to smoke independently and educated on the facility smoking policy, was observed smoking in a front patio area instead of the designated smoking area. Staff were seen entering and exiting without intervening, despite a care plan goal to prevent smoking-related accidents and observe for unsafe smoking behaviors. The DON acknowledged prior awareness that this resident did not always follow the smoking policy and confirmed that smoking was permitted only in the designated outdoor area equipped with safety devices.
The facility failed to develop and update comprehensive, person-centered care plans after multiple resident-to-resident physical altercations. In several cases, a resident physically assaulted a roommate or another resident, or a resident experienced physical aggression from another resident, as documented in progress notes and incident reports. Although IDT meetings were held and new behavioral interventions such as frequent checks and psych referrals were identified, these behaviors and interventions were not incorporated into the affected residents’ care plans. The SW and MDS LVN confirmed that behavior-related care plans were missing, contrary to facility policy requiring care plans to include identified problems, risk factors, measurable objectives, and timeframes.
A resident with severe cognitive impairment and multiple medical conditions had dementia with anxiety documented as an active problem in a physician progress note, but this diagnosis was not included on the resident’s electronic medical diagnosis list. The resident was unable to report his own medical problems due to low cognitive function. The DON confirmed that both she and the primary care physician recognized dementia with anxiety as an active diagnosis, acknowledged that the electronic list was inaccurate, and stated she was responsible for ensuring accurate diagnosis lists, despite facility policy requiring complete documentation of changes in medical condition.
A resident who was readmitted with a Foley catheter did not have corresponding catheter care orders in the administration record, despite receiving care such as cleaning and bag changes. Staff interviews and record reviews confirmed that while care was provided, the lack of proper orders prevented accurate documentation in the medical record, resulting in incomplete clinical records.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room after damaging a privacy curtain, but the guardian was not notified in writing or given the reason for the change. Staff believed the move was temporary and did not follow facility policy requiring notification and consent from the resident's representative.
A resident with severe cognitive impairment and a history of wandering exited the facility, resulting in police intervention. Staff were unable to redirect the resident, and emergency contacts were not notified of the incident until days later, learning about it through social media instead of from the facility. Facility policy required prompt notification of significant changes, but this was not followed, and there was no documentation of timely communication.
Two residents' care plans were not updated by the interdisciplinary team after significant behavioral changes, including repeated safety-impacting behaviors and an episode of suicidal ideation. Staff and administrative interviews confirmed that these behaviors were known but not reflected in the care plans, contrary to facility policy.
A resident with complex medical needs, including dysphagia and reliance on G-tube feedings, was repeatedly served regular textured foods instead of the prescribed pureed diet with thickened liquids. Staff interviews and documentation revealed confusion about dietary orders, lack of supervision during meals, and failure to follow care plans, resulting in the resident receiving food inconsistent with her assessed needs.
A resident with multiple pressure ulcers and a history of refusing wound care was found with live maggots in a stage 3 heel wound after refusing care for at least a day. Staff observed that the resident often spent time outdoors and that a window screen in the room was not fully adjusted, potentially allowing flies to enter. Housekeeping did not clean the room or change linens the night the maggots were discovered, and pest control logs showed no prior issues. The facility's pest control policy was not effectively implemented, leading to this deficiency.
A resident with multiple pressure ulcers did not receive timely wound care for several wounds due to missing treatment orders and incomplete documentation. The resident, who was cognitively intact but frequently refused care and spent extended periods outside, had maggots develop in a wound after wound care was missed. Staff interviews and record reviews confirmed that wound assessments and documentation were not consistently completed as required by facility policy.
A resident with a below-the-knee amputation and multiple health conditions did not have wound care treatments properly documented in the medical record on several occasions, despite physician orders. Staff interviews revealed that wound care was sometimes performed by different nurses, and documentation was missed, making it unclear if care was provided as required.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, failing to meet required standards for meal service.
The facility failed to maintain complete food temperature logs for multiple meals over several days, with missing documentation for breakfast, lunch, and dinner. The Food Service Supervisor could not explain the missing records, and the Dietician noted the deficiency in the Sanitation Report, resulting in an unsatisfactory rating. The facility also lacked a policy requiring daily documentation of food temperatures for each meal prepared.
The facility failed to keep the kitchen steam table in safe working order, resulting in hot foods being served at unsafe temperatures and, at times, cold to residents. Staff attempted to compensate by using hot water and holding food on the stove, but the steam table remained non-operational for several days. The facility lacked a policy for maintaining essential equipment, and no foodborne illnesses were reported during this period.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
Surveyors found that the kitchen had two overhead ceiling light covers with dead brown insects and a dishwashing area vent covered in a black substance. Staff interviews confirmed awareness of these sanitation issues, and facility policies requiring cleanliness were not followed.
A resident with significant medical needs did not have working bedside or overhead lights in their room for at least 30 days, despite multiple complaints to staff. The issue persisted due to the absence of a maintenance director, lack of effective communication, and missing work order documentation. Staff confirmed the lights were necessary for safe care and resident comfort, and the deficiency led to a diminished quality of life for the resident.
In a memory care unit, inadequate supervision led to repeated incidents of resident-to-resident aggression. A resident with severe cognitive impairment and a history of wandering was physically abused by two other residents with known aggressive behaviors. The unit was often staffed by only one CNA, with the nurse assigned to multiple units, leaving residents unsupervised at times.
The facility failed to treat residents with respect and dignity during meal service. One resident consistently received her meal after her tablemate, causing dissatisfaction. Another resident received a burnt chicken patty instead of the fried chicken listed on the menu, without a substitution log. The absence of knives made it difficult for residents to eat comfortably, highlighting a lack of consideration for their dining experience.
The facility failed to provide a structured activity program tailored to residents' needs and preferences, as several residents were observed without engagement in activities despite their care plans. A resident with cognitive impairment organized some activities due to the absence of a full-time Activity Director. The activity calendar did not match actual activities, and a resident was unable to watch TV due to a non-functioning remote.
The facility failed to maintain a full-time Activity Director since November 2024, resulting in unstructured and inconsistent activities for residents. A PRN Activity Director managed activities sporadically, leading residents to organize their own activities. The Operations Manager acknowledged the absence and was in the process of hiring a new director.
The facility failed to provide necessary treatment for residents with pressure ulcers. A resident with a heel ulcer was not observed with offloading boots, despite orders for their use. Another resident at risk for ulcers was found without heel protectors, and a third resident requiring repositioning every two hours was not repositioned as needed. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to care plans and facility policies.
A facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate for a resident. Medications crucial for managing high blood pressure and swelling were administered late by Medication Aide E, who did not report the delays to the DON. The facility lacked a policy for timely medication administration.
A facility failed to properly label and store medications, leaving a medication cart unlocked and unsupervised, and storing expired insulins for three residents. An LVN left the cart unattended, and expired insulins were found in the cart, compromising resident safety and medication efficacy.
The facility failed to maintain food safety standards, with unlabeled food items lacking discard dates, missing entries in temperature and dishwashing logs, and a dietary aide not adhering to dress code policies. These deficiencies could lead to food-borne illnesses, as acknowledged by the CDM and RD.
The facility failed to adhere to infection prevention protocols, as evidenced by staff not using appropriate PPE for residents requiring Enhanced Barrier Precautions. A resident with a UTI and another with a gastric tube were involved in incidents where staff either wore insufficient PPE or none at all, despite clear signage and available supplies.
The facility's secured backyard and smoking patio area had deficiencies, including a detached chain link fence and improper use of trash cans, posing risks for resident elopement and fire hazards. Residents with cognitive impairments and behavioral issues were observed in the area. Staff interviews revealed a lack of awareness and oversight regarding these issues, and the facility failed to adhere to its smoking policy.
A facility failed to provide adequate pharmaceutical services, resulting in late medication administration and expired insulin storage. Medications were administered late to several residents with various conditions, and expired insulins were found unrefrigerated and unlabeled. The facility's policies on medication administration and storage were not followed, leading to these deficiencies.
The facility failed to maintain resident privacy and confidentiality due to two incidents involving LVNs. One LVN entered residents' rooms without knocking, while another left a computer screen open with a resident's personal information visible. These actions violated the facility's policies on privacy and confidentiality.
The facility failed to maintain adequate lighting in the dining room, affecting two residents with complex medical conditions. The malfunctioning fluorescent lamps resulted in dim lighting, causing discomfort and dissatisfaction. Despite attempts to fix the issue, the problem persisted over several days, impacting the residents' ability to see their food and contributing to feelings of isolation and depression.
A facility failed to ensure a comprehensive person-centered care plan for a resident, resulting in a discrepancy between the resident's documented DNR status and their expressed wish to be a Full Code. The inconsistency was confirmed by the social worker, who noted the need to verify and update the resident's code status during assessments.
A resident with a history of cognitive deficits and elopement risk was able to exit through a door without triggering the wander guard alarm, as the device was not functioning properly. Despite staff presence, the malfunction went unnoticed until the survey. The wander guard was supposed to be checked daily, but it was not functioning during the survey period, and the exact date of failure was unknown.
A facility failed to maintain a resident's nutritional status, resulting in significant weight loss. Despite the care plan requiring weekly weights and nutritional assessments, these were not conducted, leading to a 10-pound weight loss over one month. Interviews revealed that staff were aware of the weight loss but did not implement timely interventions, contrary to facility policy.
The facility failed to follow prescribed dietary menus for residents on soft bite-sized and minced moist diets, serving a full pimento cheese sandwich and non-pureed tomato basil soup instead of the required textures. Staff interviews revealed a lack of adherence to dietary guidelines and insufficient knowledge of diet preparation, posing a choking hazard to residents.
Two residents identified as elopement risks managed to leave the facility despite interventions such as wander guards and structured activities. One resident, with vascular dementia, was found at a bus station, while another, with Alzheimer's, was found at a church suffering from heat exhaustion. The facility's policies on monitoring and responding to alarms were not effectively implemented, leading to these incidents.
The facility failed to appoint a licensed administrator within the required timeframe after terminating the previous administrator. Employee B, who was not licensed, served as the administrator for 39 days. Although she was in the process of obtaining her NHA license, she was not yet licensed at the time of her appointment. Administrator C, a licensed administrator from another facility, provided oversight only once or twice a week. This situation could potentially decrease the quality of care provided to residents.
A facility failed to document a thorough investigation of a resident-to-resident altercation where a resident with a history of behavioral issues threw a cup at another resident during an argument. The incident was not properly investigated by the former administrator, and the current AIT could not locate the necessary report. This lack of documentation and investigation could place residents at risk for further abuse.
A facility failed to conduct proper pre- and post-dialysis assessments for a resident, as required by professional standards. The resident did not receive complete vital sign assessments before leaving for dialysis on eight occasions and after returning on nine occasions. Interviews with the DON and an RN highlighted the importance of these assessments to ensure resident stability, but the DON was unaware that previous dates' assessments were used. Attempts to interview the responsible LVN were unsuccessful.
The facility failed to maintain proper infection control practices, as observed during skin assessments and wound care for multiple residents. An LPN consistently washed hands for less than the recommended duration and did not allow alcohol-based hand rub to dry before donning gloves, increasing the risk of infection transmission. Interviews with staff revealed a misunderstanding of proper hand hygiene procedures, despite existing guidelines.
A resident with diabetes and end-stage renal disease developed an unstageable pressure ulcer due to the facility's failure to notify the wound care physician and family of significant changes in the wound. Despite having a care plan, the facility did not adhere to interventions, resulting in the wound progressing to a severe state. Interviews revealed a lack of documentation and communication, with the wound care physician unaware of the wound's deterioration until the resident was hospitalized.
Inaccurate MAR Documentation for Antihypertensive Medications with Parameter Orders
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and systematically organized medical records for multiple residents, specifically related to the documentation of blood pressure (BP) and pulse parameters for antihypertensive medications. For three residents with significant cardiovascular and cognitive conditions, the Medication Administration Records (MARs) showed that BP medications were documented as administered even when recorded vital signs were outside the physician-ordered parameters to hold the medications. The facility’s Medication Administration policy required staff to obtain and record vital signs when applicable or per physician orders and to hold medications when vital signs were outside prescribed parameters, but the documentation did not accurately reflect whether medications were held or given. For one male resident with vascular dementia, congestive heart failure, hypertension, and a history of cerebral infarction, orders for Lisinopril and Carvedilol included parameters to hold the medications for systolic blood pressure (SBP) less than 110 and pulse less than 60. The April MAR showed that Carvedilol was documented as administered during an evening medication pass when the SBP was recorded at 109/57, which was below the ordered SBP parameter. The MAR listed the hold parameters, but there was no corresponding nursing progress note addressing the out-of-parameter SBP or clarifying whether the medication was actually given or held. For a second male resident with vascular dementia, cerebral infarction, and hypertensive heart disease, orders for Carvedilol, Hydralazine, and Losartan included parameters to hold the medications for SBP less than 100 or 110 (depending on the drug) and pulse less than 60. The March MAR showed that all three antihypertensive medications were documented as administered during a morning medication pass when the pulse was recorded at 54, below the ordered pulse parameter. The MAR reflected the hold parameters, but there were no nursing progress notes documenting the out-of-parameter pulse or any clinical decision-making related to the medications. For a female resident with vascular dementia, hypertension, and chest pain, orders for Lisinopril, Nifedipine ER, and Metoprolol Tartrate included parameters to hold the medications for BP less than 110/60 and pulse less than 60. The April MAR showed multiple instances where these medications were documented as administered despite recorded vital signs that were outside the ordered parameters, including pulses of 57, 59, and 58, and BPs with diastolic readings below 60. These discrepancies occurred on several different days and times prior to the resident’s discharge to the hospital for a UTI. There were no nursing progress notes documenting that BP or pulse readings were out of parameters on those dates. Surveyor observations of current medication passes by CMAs and LVNs showed that staff were obtaining BP and pulse, entering them into the electronic record (PCC), and checking parameters before selecting and administering antihypertensive medications, which was described as following professional guidelines. In interviews, CMAs and LVNs consistently stated that they always check BP and pulse, follow parameters, and hold medications when vital signs are outside ordered ranges, and one LVN acknowledged that she may have clicked the wrong box in the MAR, resulting in incorrect documentation even when a medication was held. The DON reported that there was no process in place to verify whether staff actually gave or held medications when vitals were outside parameters and confirmed that, although parameters were considered best practice and referenced in the medication policy, there was no separate policy requiring parameters. The policy review confirmed that staff were expected to obtain and record vital signs when applicable and to hold medications for vital signs outside prescribed parameters, and to correct discrepancies and report them to the nurse manager, which did not occur in the cited cases.
Failure to Notify Representatives and Physicians After Sensitive Resident Incident
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify two residents’ representatives and physicians after an incident in which one resident was found partially disrobed in another resident’s room. Resident #1, a female with Alzheimer’s disease residing on the memory care unit and receiving hospice services for senile degeneration of the brain, was admitted for LTC due to cognitive impairment and required staff assistance with dressing and activities. During a nursing shift change, RN B documented that Resident #1 was found in Resident #2’s room, in bed A, nude from the waist down and covered with a blanket, while Resident #2 was seated on his walker at the other end of the room looking out the window. Both residents stated they did not know what was going on, and Resident #1, oriented only to person, denied anything had happened and reported feeling fine. RN B’s progress note indicated that Resident #1 was assessed with no abnormal findings, dressed, and redirected to her own room, and that staff would continue to monitor her behavior. However, a review of the medical records for both Resident #1 and Resident #2 from the date of the incident through the survey period showed no documentation that either resident’s physician or representative had been notified of the incident. Resident #1’s care plan and physician’s orders required that family and hospice be kept informed of changes in condition and that hospice be contacted for any changes or concerns, but there was no record of immediate notification to the representative or physician regarding this event. Interviews further confirmed the lack of timely notification. Resident #1’s representative reported learning of the incident about a week later from the hospice RN and stated he had been in the facility the day after the incident and met with the social worker and ADON without being informed of what had occurred. Resident #2’s representative stated she had not received any report of the incident. RN B stated she had reported the incident to the DON and ADON, while the ADON stated she believed RN B had already notified both residents’ representatives and physicians but had not verified this. The hospice RN reported she learned of the incident from staff during a routine visit and later discovered that Resident #1’s representative had not been informed. The facility’s policy on Notification of Changes required prompt informing of the resident, consultation with the physician, and notification of the representative when there is a change requiring notification, including for residents incapable of making decisions, but this was not followed in this incident.
Failure to Report Alleged Abuse Incidents Involving Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report alleged violations involving abuse, neglect, or exploitation within required time frames to the state survey agency and other appropriate authorities. Facility records show that a female resident with Alzheimer’s disease, severe cognitive impairment, and on hospice services was admitted to the memory care unit for LTC. Her care plan and physician’s orders indicated significant cognitive and functional impairment, dependence on staff for activities, and the need for close supervision and communication with hospice regarding any changes or concerns. On one occasion, nursing progress notes documented that this resident was found in a male resident’s room, sitting on his bed, nude from the waist down and covered with a blanket, while the male resident was fully clothed in the room with the door closed. Interviews and record reviews revealed that on the date of the semi-nude incident, staff on duty, including an RN, LVN, CNA, and the ADON, became aware that the cognitively impaired female resident was missing from her usual location and subsequently found her in the male resident’s room partially disrobed. Staff assessed both residents, reported no injuries, dressed and redirected the female resident, and reported the incident internally to the ADON, DON, and Administrator. Additionally, nursing notes from an earlier date documented that the same male resident, who had severe dementia and anxiety with a BIMS score indicating severe cognitive impairment, had been verbally aggressive toward the same female resident, stating “She is mine and will do whatever I say,” causing the female resident to cry and requiring staff redirection and reassurance. Despite these documented events and the facility’s written abuse, neglect, and exploitation policy requiring immediate investigation and reporting of all alleged violations and suspicions of abuse, neglect, or exploitation to the Administrator, state agency, and APS within specified time frames, the facility did not submit any reports to the state agency for these incidents. The Administrator and DON acknowledged they had not received a report of the earlier verbal aggression incident and confirmed they did not report the semi-nude incident to the state agency. They stated they believed the semi-nude incident was normal wandering and disrobing behavior for confused residents and that nothing had happened between the two residents, and therefore they did not consider it a suspicion of abuse, neglect, or exploitation, resulting in a failure to report as required by facility policy and regulation.
Failure to Investigate and Report Incident Involving Partially Disrobed Resident in Another Resident’s Room
Penalty
Summary
The deficiency involves the facility’s failure to investigate and report an incident in which one resident with Alzheimer’s disease and on hospice services was found partially disrobed in another resident’s room. The first resident, a female in the memory care unit (MCU) with severe cognitive impairment and dependent on staff for dressing and lower body care, was documented in nursing notes as being found on the bed in a male resident’s room, nude from the waist down, with only a blanket covering her. The male resident, who also resided in the MCU, was fully clothed, sitting on his walker at the other end of the room, and the door to the room was closed. When questioned, both residents stated they did not know what was going on, and the female resident, oriented only to person, denied anything had happened and reported feeling fine. The male resident involved had severe dementia and anxiety, with an admission MDS showing a BIMS score of 3/15, indicating severe cognitive impairment, though he could usually understand others and make himself understood. The female resident’s care plan and physician’s orders indicated she was receiving hospice services for senile degeneration of the brain, had impaired physical functioning related to cognitive impairment, and required staff assistance with dressing and activities. On the date of the incident, during shift change, the oncoming RN and the off-going LVN could not locate the female resident, searched for her, and then found her semi-nude in the male resident’s room. The RN documented assessing both residents, finding no injuries, dressing the female resident, and reorienting her to her own room. Despite this incident meeting the facility’s policy threshold for an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation, the facility did not initiate or document a thorough investigation or submit an investigation summary report to the State Survey Agency within 5 working days. The ADON reported that she received the report of the incident from the RN and stated she informed the DON and the Administrator, who was the abuse prevention coordinator. However, the Administrator and DON later stated they did not consider the event a suspicion of abuse, neglect, or exploitation, characterizing it instead as normal wandering and disrobing behavior for confused residents, and therefore did not treat it as an allegation requiring investigation and reporting. As a result, there was no evidence that the facility thoroughly investigated the incident, implemented measures to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress, or reported the results of an investigation to the appropriate officials as required.
Failure to Care Plan Resident-to-Resident Behavioral Interactions in Memory Care Unit
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents in the memory care unit. For Resident #1, who had Alzheimer’s disease, severe cognitive impairment, and was receiving hospice services, the care plan dated 4/22/2026 did not contain any specific interventions addressing another resident’s unwanted focused attention toward her. Resident #1’s representative reported that Resident #2 had become fond of Resident #1, habitually having her sit next to him, and that staff had informed him of this behavior. He also stated that he frequently visited and physically removed Resident #1 from Resident #2’s area, indicating an ongoing pattern of interaction that was not reflected in Resident #1’s care plan. For Resident #2, who had severe dementia, anxiety, and a BIMS score of 3 indicating severe cognitive impairment, the care plan dated 4/22/2026 documented socially inappropriate behaviors with generic interventions such as documenting specific instances of inappropriate behavior, including context, duration, and impact on others. However, there was no care plan specifically addressing Resident #2’s focused attention and behaviors toward Resident #1. Nursing progress notes documented that on 3/31/2026, Resident #2 became verbally aggressive when Resident #1 was taken to her room for care, stating "She is mine and will do what ever I say," causing Resident #1 to cry. The nurse redirected Resident #2 and reassured Resident #1 that she was safe, but these specific behaviors and staff responses were not incorporated into a revised, individualized care plan. Interviews with staff further confirmed that the care plans had not been updated to reflect the ongoing situation between the two residents. An LVN and a CNA reported that Resident #2 had become increasingly focused on Resident #1 over the prior month, scolding her when he perceived she was not fast enough and cussing at her. They stated they monitored both residents and intervened for safety by redirecting one or both away from each other, but acknowledged that neither resident had a revised care plan detailing these monitoring and redirection interventions. The Administrator and DON stated that the expectation was for nursing staff to report unusual incidents and their interventions to the IDT so that a revised care plan could be developed, and acknowledged that not doing so could result in residents not having an accurate care plan, which was inconsistent with the facility’s own care plan policy requiring comprehensive, person-centered care plans addressing identified medical, physical, mental, and psychosocial needs.
Failure to Obtain Ordered Urinalysis After Resident Fall
Penalty
Summary
The facility failed to provide or obtain ordered laboratory services for one resident when an LVN did not secure a urinalysis (UA) as part of the evaluation after a fall. The resident was an elderly female with a history of falling, hemiparesis following a cerebral infarction affecting the left side, and type II diabetes, admitted for LTC and assessed with severe cognitive impairment (BIMS score of 3/15). Her care plan documented urinary incontinence, monitoring for signs and symptoms of UTI, a history of falls, and an intervention for labs and a UA to be collected following an actual fall on 04/07/2026, with the UA to be initiated on 04/08/2026. A nursing progress note by LVN G on 04/08/2026 at 11:20 AM stated that the NP ordered a CBC and UA as part of the action plan for the recent fall. A review of the physician’s orders from 04/01/2026 through 04/24/2026 showed no order for a UA, and the UA was never completed. During interview, the NP stated she could not recall the specific report from the LVN about the fall but indicated it would be reasonable for her to order a CBC and UA to assess for potential infection and possible rationale for falls. In a separate interview, LVN G stated that the NP requested only a CBC and that she coordinated and obtained that lab draw. LVN G further stated that, although her note documented that the NP wanted both a blood draw and a UA, the note was not complete and should have indicated that the UA was to be done only if the resident showed UTI symptoms such as confusion, dysuria, or foul-smelling urine; therefore, she believed no UA order was in place and did not obtain one. In a joint interview, the DON and Administrator stated that nurses were expected to support and implement prescribers’ new orders and that LVN G was responsible for coordinating the NP’s order for a UA and had not done so, which they stated could deny prescribers the opportunity to intervene by not having laboratory services reported.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain personal privacy during personal care for one resident when a CNA opened the resident’s door while he was lying in bed wearing only a brief. The resident had been admitted with malnutrition, cerebral infarction due to small artery occlusion or stenosis, dysphagia following cerebral infarction, a gastrostomy for enteral feeding, and a cognitive communication deficit. His admission MDS showed he was severely cognitively impaired, totally dependent for all ADLs including toileting and personal hygiene, and had a feeding tube. His care plan documented impaired communication related to CVA with aphasia, cognitive communication deficit, impaired physical functioning, debility/weakness, hemiplegia/hemiparesis, neurological disease, prolonged hospitalization, lack of coordination, and abnormalities of gait and mobility, and that he required one to two persons for toileting and hygiene, as well as enteral tube feeding for oropharyngeal dysphagia and failure to thrive. During observation, the CNA exited the resident’s room and opened the door, exposing the resident in bed closest to the door. Although the privacy curtain was pulled, it did not extend around the foot of the bed, leaving the resident visible while wearing only a brief and connected to a G-tube. The CNA reported she opened the door to get help from another CNA because the resident, normally a one-person assist, was stiffer than usual and had paralysis on his left side, and she needed assistance to turn him to secure his brief. She stated she typically pulled the privacy curtain to the edge of the bed and never all the way around because it was not long enough, and in this instance did not draw it to cover the foot of the bed closest to the door to avoid exposing the resident to his roommate. The resident did not engage in conversation during an attempted interview and did not speak. The DON stated staff should ensure privacy during care and that exposing a resident during care would be a violation of privacy and could cause embarrassment. Facility policy on Quality of Life – Dignity required staff to promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Provide Ordered Podiatry Care and Foot Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and podiatry services in accordance with professional standards and its own policy for a resident who required assistance with personal hygiene. The resident was admitted with paranoid schizophrenia and generalized anxiety and had a quarterly MDS showing a BIMS score of 13/15, indicating no cognitive impairment, but a need for substantial to maximum assistance with personal hygiene. The resident had a physician’s order for podiatry care, and a local podiatry group was providing services to multiple residents in the facility; however, the resident’s name did not appear on the podiatry schedule. On observation, the resident’s toenails were approximately 1/2 inch past the nailbeds, with very thick great toenails, and the resident reported needing them cut, stating that a CNA had tried to clip them but they were too thick and that he preferred podiatry to do it. He also stated he had not seen a podiatrist since admission. The charge nurse (LVN) acknowledged during observation that the resident’s toenails were long and needed cutting and that the great toenails were very thick, but she stated she had not noticed the length of his toenails before that day and that there was nothing in the progress notes indicating a need for podiatry referral. The DON stated that staff would not document the condition of long toenails on weekly skin sheets and that she did not necessarily require staff to document the need for podiatry care in a progress note, instead expecting staff to verbally inform the social worker so a referral could be made. The social worker reported that any staff could notify her of the need for podiatry care and that review of the last podiatry list showed the resident had not been seen. The facility’s undated “Podiatry Services” policy stated that residents requiring foot care with complicating conditions would be referred to qualified professionals and that employees should refer identified foot care needs to the social worker, who would assist with appointments and transportation. Despite these orders and policies, there was no documented or acted-upon referral for this resident’s podiatry care, resulting in prolonged overgrown and thick toenails.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program for a resident on Enhanced Barrier Precautions (EBP). The resident was admitted with multiple diagnoses including malnutrition, cerebral infarction with resulting dysphagia, cognitive communication deficit, hemiplegia/hemiparesis, and required a feeding tube. The admission MDS showed the resident was severely cognitively impaired and totally dependent for all ADLs, including toileting and personal hygiene. The care plan documented that the resident had impaired communication related to CVA and other neurological and functional deficits, required one to two persons for toileting and hygiene, and was on EBP due to an indwelling medical device, with an intervention directing staff to don gown and gloves during high-contact personal care activities. On the survey date, a CNA exited the resident’s room after providing peri-care and was observed not wearing gloves, a mask, or a gown, despite an EBP sign posted at the door instructing staff to wear gloves, gown, and mask for high-contact personal care. The resident was observed in bed wearing a brief and connected to a G-tube. In interview, the CNA stated she had been changing the resident and acknowledged she was not wearing PPE. She reported there was no PPE in the room, in the caddy on the door, or in nearby door caddies, and admitted she did not inform any nurse or look for PPE on other halls or in the storage closet. She further stated she should have been wearing PPE while providing direct care and because the resident had a PEG-tube. Additional interviews and observations showed that HR/Central Supply staff had been ordering PPE weekly for about two years, with deliveries the next day, and that there was no central storage room but supply closets on three halls, including the resident’s hall. Observation of the supply closet on that hall revealed available PPE, including gowns, masks, and gloves. HR staff stated that floor staff and resident ambassadors were responsible for restocking PPE caddies on doors of residents on EBP. The ADON, who served as the infection preventionist, reported she had recently restocked PPE caddies after the DON noted they were low, and she acknowledged some caddies had been empty or had only a few gowns. The DON stated that residents were placed on EBP for indwelling medical devices or open wounds, that signs and PPE caddies were placed at their doors, and that staff were expected to wear gloves and gowns to minimize infection spread. The facility’s written EBP policy required gowns and gloves to be made available immediately near or outside the resident’s room for residents with wounds or indwelling medical devices, such as feeding tubes.
Failure to Enforce Designated Smoking Area Policy
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible by not enforcing its smoking policy for one resident. The resident had a history of bipolar disorder, depression, anxiety, schizophrenia, and post-traumatic stress disorder, but a BIMS score of 15/15 indicating no cognitive impairment. Her initial smoking evaluation documented no deficits preventing her from smoking independently and unsupervised, and staff had reviewed the smoking policy with her, with documentation that she verbalized understanding. Her care plan, revised on 6/16/25, identified her as a smoker with a goal to prevent accidents while smoking and to observe her for unsafe smoking behaviors or attempts to obtain smoking materials from outside sources. On observation, the resident was seen sitting in a wheelchair and smoking a cigarette in the front patio area, which was not the designated resident smoking area. When asked if she was allowed to smoke in the patio, she stated she was allowed to sign out and could smoke when she left the premises, and did not answer when asked again if she could smoke in the patio. Staff were observed entering and exiting the facility during this time, and none approached the resident. The DON reported awareness that the resident did not always follow the smoking policy and stated she had previously seen the resident smoking in the front patio. The DON confirmed that per policy the resident was only allowed to smoke in the designated smoking area at the back of the facility, where metal ashtrays, a fire blanket, and a fire extinguisher were located, and stated that all staff were responsible for monitoring and reporting residents who smoked outside designated areas because the resident could start a fire and other residents could get hurt.
Failure to Care Plan Resident-to-Resident Physical Altercations and Behavioral Risks
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents who were involved in resident-to-resident physical altercations. For one resident with schizophrenia, anxiety disorder, and mild cognitive impairment, progress notes documented that staff heard yelling and found him standing over his roommate with his fist raised, and the resident stated he had punched the roommate because of how the roommate spoke to him. Despite this documented incident of physical aggression, the resident’s care plan, with a target date of 01/07/2026, did not include any problem, goal, or interventions addressing his physical aggression toward another resident. Subsequent observations showed the resident interacting with others without aggressive behavior, and he denied the incident during interview, but the absence of a behavior-related care plan remained. Another resident with schizoaffective disorder, anxiety disorder, and paraplegia had a Significant Change MDS showing intact cognition and behavioral symptoms not directed toward others. A progress note documented that staff heard yelling, entered the room, and found this resident lying in bed with his roommate standing over him with a balled fist above his head; the resident reported being hit in the head, after which he was removed and assessed. His care plan, with a target date of 02/02/2026, did not include any care plan entry reflecting that he had experienced physical aggression from another resident. During interviews, the resident reported only one such incident, stated staff had moved him from the room, and denied having exhibited behaviors himself. The social worker and the MDS LVN both reviewed the care plans and confirmed they could not locate behavior-related care plan entries for either resident, despite stating that such incidents were typically care planned to provide interventions and alert staff to behaviors and safety concerns. Two additional residents with significant cognitive impairment and behavioral histories were also involved in resident-to-resident altercations without corresponding updates to their care plans. One resident with Alzheimer’s disease, diabetes, and depression had an incident report documenting that she hit another resident in a secure unit; staff separated them and assessed both residents with no injuries noted, and an IDT meeting the next day identified new interventions such as 15-minute checks and referral to psychiatric services. However, her comprehensive care plan did not reflect the altercation or the new interventions. Another resident with dementia, psychotic disorder, depression, and hallucinations had an incident report indicating he pulled another resident out of bed because the other resident was sleeping in his bed; staff separated and assessed them with no injuries noted, and an IDT meeting identified new interventions including 15-minute checks and psychiatric referral. His comprehensive care plan likewise did not include the altercation or the new interventions. The social worker acknowledged forgetting to create behavior care plans for these residents after the IDT meetings, despite facility policy requiring comprehensive, person-centered care plans that incorporate identified problem areas, risk factors, measurable objectives, and timeframes.
Inaccurate Electronic Diagnosis List for Resident With Dementia and Anxiety
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of complete and accurate medical records for one resident. The resident’s face sheet listed multiple diagnoses, including hyperlipidemia, cerebral infarction, encephalopathy, and hypertension. The admission MDS documented a BIMS score of 7/15, indicating severe cognitive impairment, and showed the resident required substantial/maximal assistance with most ADLs such as sit-to-stand, chair-to-bed, and toilet transfers. A physician progress note dated 12/01/2025 identified dementia with anxiety as one of the resident’s active medical problems. However, review of the resident’s electronic medical diagnoses list on 01/06/2026 showed that dementia with anxiety was not included as an active diagnosis. During observation, the resident was seen sitting in a wheelchair near the nursing station and was unable to state his medical problems due to low cognitive function. In an interview, the DON confirmed that the resident had dementia with anxiety, that the primary care physician had documented this diagnosis, and that the diagnosis was missing from the electronic medical diagnosis list. The DON acknowledged the inaccuracy and stated she was responsible for ensuring residents had accurate medical diagnosis lists. The facility’s “Charting and Documentation” policy required that all services and changes in a resident’s medical condition be documented in the medical record.
Failure to Maintain Accurate Foley Catheter Orders and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident who was readmitted from the hospital with a Foley catheter. Upon review, it was found that the resident's November administration orders did not include any orders for Foley catheter care, despite the resident having an indwelling catheter in place. The resident's care plan and physician order summary indicated the presence of a Foley catheter and outlined care interventions, but these were not reflected in the administration record, which is used by nursing staff to document care provided. Interviews with staff confirmed that the resident returned from the hospital with a Foley catheter and that care, such as cleaning the insertion site and changing the drainage bag, was being provided. However, staff also stated that there should have been specific orders for Foley catheter care in the administration record to ensure proper documentation and completion of required tasks. The Director of Nursing acknowledged that the Foley catheter order was entered into the electronic medical record but was not activated on the administration record, resulting in a lack of documentation for the care provided. Record reviews further showed that the facility had a policy requiring catheter care every shift and as needed, and that staff had received in-service training on Foley catheter care. Despite this, the absence of Foley catheter care orders in the administration record meant that the care provided was not properly documented, which could affect the accuracy and completeness of the resident's clinical records.
Failure to Notify Guardian of Resident Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, to a resident's guardian prior to moving the resident to a different room. The resident, an elderly male with diagnoses including vascular dementia, chronic obstructive pulmonary disease, and interstitial pulmonary disease, was rarely or never understood, had significant memory problems, and was severely impaired in daily decision making. The resident was at risk for injury due to wandering and resided in a secure unit. On the day of the room change, there was no documentation or notification to the resident's guardian regarding the reason for the move, nor was there any evidence of consent or the right to refuse being offered. Staff interviews revealed that the room change occurred after the resident pulled down a privacy curtain, damaging the curtain rail. Staff, including an LPN, HR, and the DON, believed the move was temporary and did not notify the guardian, as required by facility policy. The DON later confirmed that there was no documentation of guardian notification, and the guardian stated he did not recall being informed of the room change. Facility policy required prompt notification of the resident's representative when a room assignment change was needed, but this was not followed in this instance.
Failure to Notify Resident Representatives After Significant Behavioral Incident
Penalty
Summary
The facility failed to notify a resident's physician and representatives following a significant change in the resident's behavior, specifically an increase in exit-seeking behavior that resulted in police intervention. The resident, a male with diagnoses including schizoaffective disorder, type 2 diabetes mellitus, and dementia, had a documented history of wandering and was assessed as being at risk for elopement. On the night of the incident, the resident left the facility through a secured door, setting off an alarm, and was pursued by staff who were unable to redirect him. The situation escalated to the point where police were called, and the resident was physically restrained and returned to the facility by law enforcement. Despite the seriousness of the event, there was no documentation that the resident's emergency contacts were notified of the incident until several days later. Both emergency contacts reported learning about the incident through a family member who saw it on social media, rather than from the facility itself. Interviews with staff and administration confirmed that there was no immediate notification to the resident's representatives, and the facility's electronic medical record did not show any timely communication regarding the police intervention or the resident's attempted elopement. The facility's policy required prompt notification of the resident, physician, and representative in the event of significant changes in condition or incidents involving the resident. However, the Director of Nursing stated that the incident was not considered a change of condition due to the resident's history, and therefore, notification was not deemed necessary at the time. This lack of timely communication was confirmed by both the DON and the administrator, as well as by the absence of documentation in the resident's records.
Failure to Update Care Plans Following Behavioral Changes
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for two residents. For one resident with vascular dementia and severe cognitive impairment, the care plan did not address known behaviors such as stripping the bed and pulling down the privacy curtain, despite multiple incidents and staff awareness of these behaviors. Staff interviews confirmed that these behaviors had occurred more than once, and that the care plan had not been updated to reflect these safety-impacting actions. Another resident, diagnosed with schizoaffective disorder and major depressive disorder, experienced an episode of suicidal ideation, which resulted in her being sent to the emergency room for evaluation. Documentation and staff interviews revealed that this was the first such incident for this resident, and although she was receiving psychological services, her care plan was not updated to reflect the new behavior of suicidal ideation. The facility's policy required that such behavioral changes be care-planned, but this was not done following the incident. Record reviews and staff interviews indicated that the interdisciplinary team did not consistently update care plans to reflect significant changes in residents' behaviors or conditions. This lack of timely care plan revision could result in staff not having the necessary information to provide appropriate interventions, as documented in the facility's own policy and as acknowledged by administrative staff during interviews.
Failure to Provide Prescribed Therapeutic Diet and Food Texture
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Parkinson's Disease, dysphagia, chronic respiratory failure, diabetes, and legal blindness, did not receive food prepared in accordance with her prescribed therapeutic diet. The resident's care plan and physician orders specified a mechanically altered, pureed diet with mildly thick liquids, and most of her nutrition was to be provided via G-tube feedings. Despite these orders, the resident was observed receiving regular textured foods, such as scrambled eggs, refried beans, and bread, on her breakfast tray. Staff interviews confirmed that the resident routinely received pleasure trays with regular textured foods, and there was confusion among dietary and nursing staff regarding the existence and appropriateness of orders for these pleasure trays. The facility failed to ensure that food was prepared and served in a form that met the resident's individual needs as outlined in her comprehensive assessment and care plan. Multiple staff members, including CNAs, LVNs, and the dietary manager, acknowledged that the resident required assistance to eat, could not use utensils independently, and should not have been given regular textured foods due to her swallowing difficulties and lack of dentures. The dietary manager and registered dietitian were unaware of any physician order for pleasure trays, and the registered dietitian minimized concerns about the risk of aspiration from the foods provided. Additionally, the resident's responsible representative and several staff members reported that the resident was not consistently supervised during meals, despite her need for assistance and risk of choking or aspiration. Documentation and interviews revealed ongoing issues with communication and adherence to dietary orders. The facility's policy required that diets be served according to physician orders and that staff check meal trays for compliance with diet cards, but this was not consistently followed. A grievance had previously been filed regarding the resident receiving non-compliant foods, and staff interviews indicated that concerns about the resident's diet and supervision during meals had been raised multiple times without resolution. The administrator confirmed there was no facility policy specifically addressing therapeutic diets, and was unaware that the resident was receiving pleasure trays at every meal.
Failure to Maintain Effective Pest Control Program Resulting in Maggot Infestation in Wound
Penalty
Summary
A deficiency occurred when the facility failed to maintain an effective pest control program, resulting in a resident being found with live maggots in a stage 3 pressure ulcer on the right heel. The resident, a 32-year-old male with multiple pressure ulcers, paraplegia, and a history of refusing wound care, was admitted with several wounds but no maggots present at admission. Over the course of his stay, the resident intermittently refused wound care, and on the day maggots were discovered, he had refused care for at least one day. Nursing staff observed maggots in the wound dressing and notified the physician, but the resident initially refused to be sent to the emergency room. Observations and interviews revealed that the resident often spent extended periods outdoors and sometimes refused wound care, which contributed to the wound's condition. Staff noted that the dressing was sometimes moist and that the resident's room had a window screen that was not fully adjusted, potentially allowing flies or gnats to enter, although no flies or gnats were observed at the time of inspection. Additionally, flies were observed in another resident's room, and staff reported that food debris sometimes attracted flies, but no infestation was documented. The facility's pest control logs indicated regular pest control visits, but no issues were noted prior to the incident. Housekeeping practices were found to be inconsistent, as the resident's room and linens were not cleaned or changed on the night the maggots were discovered due to the absence of housekeeping staff. Nursing staff did not recall whether the room was cleaned or linens changed that night. The Housekeeping Manager confirmed that deep cleaning and linen changes did not occur until the following afternoon. The facility's pest control policy required the building to be kept free of insects and rodents, but the lack of timely cleaning and environmental controls contributed to the deficiency.
Removal Plan
- Resident #1's wound was cleansed per wound protocol when maggots were discovered.
- Resident #1's room was cleaned and sanitized in accordance with the facility's cleaning and disinfection policy.
- A facility-wide environmental inspection was completed by the Maintenance Director to ensure all windows, screens, and entry points were intact and secure.
- Three additional fly zap lights were ordered and installed in B Hall Dining Room, C Hall Dining Room, and E Hall dining room.
- The effectiveness of the newly installed Zap Lights will be monitored utilizing the environmental checklist by the Housekeeping Supervisor and Maintenance Director or designee.
- The Pest Prevention Technician assisted the facility with the wipe down method in rooms of residents with treatment orders, entailing wiping down surfaces and walls.
- A comprehensive skin and wound audit was completed for all residents with pressure injuries to ensure no other residents were affected.
- All staff were in-serviced on the facility's Pest Control Program, including pest prevention, environmental inspection, and staff reporting.
- Training provided to all staff on the cleanliness of resident rooms to ensure rooms remain as free as possible of items that may attract pests, and on cleaning procedures in the event pests are identified.
- Housekeeping cart is available in E hall housekeeping closet for after-hour use.
- Pest control vendor visits increased and three additional fly lights installed in key areas.
- Maintenance initiated an environmental inspection log for all window seals, screens, and potential pest entry points.
- Environmental Services implemented a cleaning checklist focusing on food debris and sanitation in resident rooms and dining areas.
- Nurses received re-education on wound care refusal documentation, physician notification, and resident education procedures.
- The Quality Assessment and Assurance Committee will review the pest control log for any pest control issues, and the Admin/DON/designee will complete 5 observations.
- If any pest control issues or deficient practices are discovered, the Admin/DON/designee will provide additional training for staff, including pretest, inservice, post-test, and return demonstration.
- The results of the Admin/Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations.
- The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with multiple pressure ulcers received necessary treatment and services consistent with professional standards of practice. Upon admission, the resident had nine wounds, including several stage 3 and stage 4 pressure ulcers and a deep tissue injury. Treatment orders for five of these wounds were not implemented for 12 to 13 days, and there was no documentation on the Treatment Administration Record (TAR) indicating whether wound care was provided to these wounds during that period. Additionally, weekly wound assessments were not completed for five of the nine wounds on a specified date, as required by the resident's care plan and facility policy. The resident was cognitively intact and frequently refused care, preferring to spend extended periods outside and declining to return indoors for wound care and medication administration. Nursing notes documented repeated refusals of wound care and medication, as well as the resident's noncompliance with recommended treatment. Despite these refusals, there was a lack of consistent documentation regarding whether wound care was attempted or provided, and treatment orders for several wounds were delayed. The facility's staff, including the treatment nurse and DON, acknowledged that the absence of timely treatment orders and incomplete documentation could result in wounds not being treated as required. The situation escalated when maggots were discovered in one of the resident's wounds, specifically the right heel, after a period of missed wound care. Interviews with staff confirmed that the resident's wounds were not always assessed or treated due to both the resident's refusals and lapses in staff follow-through with documentation and order entry. The facility's own wound care policy required verification of physician orders and documentation of wound care provided, which was not consistently followed in this case. The deficiency was further substantiated by the lack of admission treatment orders for several wounds and incomplete weekly wound assessments.
Failure to Accurately Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically by not documenting the completion of wound care treatments as ordered. The resident, a female with a below-the-knee amputation and multiple comorbidities including osteonecrosis, diabetes, atrial fibrillation, cirrhosis, and chronic kidney disease, was readmitted to the facility and required surgical wound care four times weekly. Observations and interviews revealed that the treatment administration record did not reflect completion of wound care on three specific dates, despite physician orders and the resident's care plan requiring these treatments. During interviews, staff indicated that wound care was typically performed by a designated wound care nurse, but on at least one occasion, another nurse provided the care and failed to document it. The Director of Nursing confirmed that the treatment administration record was not marked as completed on the specified dates and acknowledged that without this documentation, it could not be confirmed whether the care was provided. The resident herself reported that wound care was not always performed daily as expected.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Incomplete Food Temperature Documentation in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by incomplete food temperature logs for multiple meals over several days. Specifically, documentation was missing for lunch meals from 7/9/25 to 7/21/25 and 7/23/25 to 7/31/25, breakfast meals from 7/24/25 to 7/31/25, and dinner meals from 7/30/25 to 7/31/25. The Food Service Supervisor (FSS) confirmed the lack of documentation and was unable to provide an explanation for the missing records. The Dietician was also aware of the incomplete logs and noted the deficiency in the Sanitation Report, which resulted in an unsatisfactory rating for the facility's food service safety. Further review revealed that the facility did not have a policy on documenting food temperatures on a daily basis for each meal prepared. When requested by the surveyor, the Administrator was unable to provide such a policy during the survey period. The facility's existing Food Preparation and Service policy, dated 2001, referenced the 'danger zone' for food temperatures but did not address documentation requirements. These findings were based on observation, interview, and record review, and affected all residents who consumed meals from the kitchen during the period in question.
Failure to Maintain Safe Operation of Dietary Equipment
Penalty
Summary
The facility failed to maintain essential dietary equipment in safe operating condition, specifically the kitchen steam table, which was not functioning for several days. Staff attempted to compensate for the non-operational steam table by adding hot water to it and keeping food items in the oven or on the stove for longer periods. Despite these efforts, observations revealed that hot foods placed on the steam table quickly dropped to unsafe temperatures and were served cold to residents. Staff interviews confirmed that the steam table had been out of service since earlier in the week, and food was served cold as a result. The facility did not have a policy in place for maintaining essential equipment, including kitchen equipment, in operational condition, and no such policy was provided to the surveyor upon request. The dietician, upon learning of the equipment failure, recommended placing boiling water in the non-working steam table and holding hot foods on the stove or oven until serving. On subsequent observation, food was served directly from the stove top or placed in a roaster with hot water before plating, and food temperatures were within regulation at that time. Staff reported that if residents complained of cold food, a microwave was available for reheating. There were no reports of foodborne illness among residents during this period. The deficiency was identified through observation, staff and dietician interviews, and review of facility records and policies.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation and cleanliness in the kitchen area, as required by professional standards for food service safety. Specifically, two overhead ceiling light covers in the cooking area contained numerous dead brown insects, and the ceiling vent in the dishwashing area was covered with a black substance. These conditions were directly observed during a kitchen inspection. Interviews with facility staff, including the Administrator, DON (who also serves as the Infection Preventionist), Dietician, and Food Service Supervisor (FSS), confirmed awareness of the issues. The Administrator and DON acknowledged the presence of brown spots and a dirty vent, while the FSS admitted to not having checked the light fixtures prior to the survey but was aware of dust on the vent. The Dietician was not previously aware of these sanitation issues. Review of facility policies indicated that all food service areas should be kept clean, sanitary, and free from insects and debris, but these standards were not met at the time of the survey.
Failure to Maintain Functional Lighting in Resident Room
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not ensuring that the bedside and overhead lights in one resident's room were operational for at least 30 days. The affected resident, a 75-year-old male with peripheral vascular disease, chronic kidney disease, a left below-the-knee amputation, and diabetes, required total assistance for transfers and mobility and had moderate cognitive deficits. Observations confirmed that both the overhead and bedside lights in his room were not working, and the resident reported that the lights had been out for five months, impacting his ability to see at night and during care activities. He stated that he had complained to nursing staff but felt ignored. Interviews with staff, including the DON, Administrator, RN, and CNA, revealed that the issue had been reported but not addressed due to the absence of a maintenance director. The facility had been relying on maintenance support from a sister facility, and work orders were maintained manually, but the log could not be located. The interim Maintenance Director was unaware of the issue and had not received a work order. Staff acknowledged the importance of functional lighting for providing care and noted that the lack of lighting had not resulted in any reported negative outcomes, but it did diminish the resident's quality of life.
Inadequate Supervision Leads to Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically involving three residents in the Memory Care Unit (MCU). Resident #61, who has severe cognitive impairment and a history of wandering, was physically abused by Resident #83 and Resident #55 on multiple occasions. Resident #83, who also has severe cognitive impairment and a history of aggressive behavior, physically battered Resident #61 by punching him in the face, pulling his hair, and dragging him across the floor. This incident occurred when Resident #61 wandered into Resident #83's room. Additionally, Resident #61 was involved in altercations with Resident #55, who has severe cognitive impairment and a history of agitation and aggression. On separate occasions, Resident #61 was punched in the nose and face by Resident #55 after entering Resident #55's room. These incidents highlight the facility's failure to adequately supervise and separate residents with known aggressive behaviors and cognitive impairments. The facility's staffing practices contributed to the deficiency, as the MCU was often staffed by only one CNA, with the nurse assigned to multiple units, leaving residents unsupervised at times. This lack of adequate supervision and monitoring allowed for repeated incidents of resident-to-resident aggression, placing residents at risk for physical abuse.
Removal Plan
- Ensure a second team member is staffed in the memory care unit.
- Complete a 100% in-service for nursing staff on staffing requirements for the memory care unit and emergency procedures.
- Utilize walkie talkies for communication between the memory care unit and general population.
- Provide immediate education to all licensed/certified nursing staff on managing difficult behaviors, de-escalation strategies, and wandering/elopement.
- Educate all facility staff on the Abuse, Neglect, Exploitation or Misappropriation Prevention Program.
- Conduct all-staff meetings to address behavioral care, focusing on de-escalation, behavior management, wandering, dementia care, and activities.
- Evaluate the facility's staffing schedules and requirements for the memory care unit and general population.
- Provide access to behavioral health services for residents with increased behaviors.
- Complete Preferences for Activity and Leisure (PAL) Cards for all residents in the memory care unit.
- Develop and ensure an ongoing long-term monitoring and oversight system to review and address concerns related to deficient practices.
- Develop a short-term monitoring system for all areas of deficient practice identified.
- Monitor use of walkie talkies.
- Conduct monitoring to determine if compliance is being sustained.
- Ensure social services attend meetings to be aware of newly identified behaviors or concerns.
- Hold an Ad Hoc QAPI meeting to review and validate the plan of removal.
- Notify the facility's Medical Director of the Immediate Jeopardy tag.
- Ensure 2 CNAs are always staffed in the memory care unit.
- Actively hire and search for new staff members to be adequately staffed.
Failure to Ensure Dignified Meal Service
Penalty
Summary
The facility failed to ensure that all residents were treated with respect and dignity during meal service, as observed in the cases of two residents. One resident expressed frustration at consistently receiving her meal after her tablemate had finished eating, highlighting a lack of synchronized meal service at the table. This delay in serving meals at the same table led to feelings of dissatisfaction and disrespect. Additionally, the facility served a fried chicken patty instead of the fried chicken listed on the menu, without maintaining a substitution log or obtaining approval for the change, which further contributed to the residents' dissatisfaction. Another resident received a chicken patty that was burnt and difficult to cut, exacerbated by the absence of knives due to safety concerns. This resident struggled to cut the patty with a fork, and the lack of appropriate utensils made it challenging for residents to eat their meals comfortably. The facility's failure to provide the correct menu items and appropriate utensils, along with the lack of a substitution log, demonstrated a disregard for the residents' rights to a dignified dining experience.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs and preferences of its residents, as evidenced by the lack of an updated activity assessment and care plan for several residents. Resident #5, who was cognitively intact and expressed interest in various activities, was observed repeatedly lying in bed watching television without any engagement in other activities. Despite her care plan encouraging socialization and participation in activities, no staff were observed conducting in-room activities with her. Resident #22, who had mild cognitive impairment and a strong interest in group activities, reported that the facility had been without a full-time Activity Director for several months. She took it upon herself to organize some activities, such as calling bingo, but noted the lack of a structured program and limited vendor presence. Her care plan indicated a need for staff assistance in activities, yet the facility failed to provide a consistent and comprehensive activity program. Resident #45, who was severely cognitively impaired and dependent on staff for activities, was observed in bed without any music or television, contrary to her care plan which emphasized the importance of activities. Additionally, the activity calendar did not match the actual activities taking place, and Resident #79, who had moderate cognitive impairment, was unable to watch television due to a non-functioning remote, leaving him without his preferred activity. The facility's failure to maintain an updated activity program and assessments for these residents highlights a significant deficiency in meeting their psychosocial and recreational needs.
Lack of Full-Time Activity Director Leads to Unstructured Resident Activities
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulations. Since November 2024, the facility has not had a full-time Activity Director. The Operations Manager confirmed that they were in the process of hiring a new Activity Director, but in the meantime, the activities program was being managed by a PRN Activity Director who only came in as needed. This PRN Activity Director attempted to organize activities by calling vendors from home and visiting the facility when possible. However, this arrangement led to a lack of structured activities for the residents. Interviews with residents and staff revealed that the absence of a full-time Activity Director resulted in residents having to organize their own activities, such as bingo and watching TV, with occasional visits from vendors and church groups. The Resident Council expressed that they felt left in limbo without a dedicated Activity Director, and residents reported that the activities were not consistent or structured. The facility's job description for the Director of Activities outlined responsibilities that were not being fulfilled, such as planning, organizing, and directing a comprehensive program of activities to meet the residents' needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as observed in three cases. Resident #67, who had a pressure ulcer on her heel, was not observed with offloading boots during multiple observations, despite physician orders and care plans indicating their necessity for wound healing. The wound care nurse acknowledged the absence of the boots and emphasized their importance in preventing infection and worsening of the wound. Similarly, Resident #5, who was at risk for pressure ulcers and had a history of skin integrity issues, was found without heel protectors while in bed. A CNA admitted to not putting the heel protectors on after changing the resident, and the facility's administration recognized the need for staff education on the importance of such treatments. Resident #45, who required repositioning every two hours due to immobility and risk of pressure ulcers, was observed not being repositioned as per her care plan. Staff interviews confirmed the failure to reposition the resident, with the LVN expressing uncertainty about why the CNAs had not performed the task. The facility's policy on repositioning and pressure injury prevention was not adhered to, as evidenced by the observations and staff interviews.
Medication Administration Delays Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate for one resident. Medication Aide E administered medications to a resident with a significant delay. Specifically, the resident's doxazosin was administered 1 hour and 28 minutes late, while hydralazine, carvedilol, and furosemide were administered 58 minutes late. These medications were crucial for managing the resident's high blood pressure and swelling due to heart failure. The resident, who had a history of hypertensive chronic kidney disease with end-stage kidney disease, required timely medication administration to manage his condition effectively. During an observation, Medication Aide E acknowledged being late in administering medications and had not reported this to her direct supervisor, the Director of Nursing (DON). The DON stated that the expectation was for medications to be administered within 1 hour of the prescribed time and that any potential late administration should have been reported. However, Medication Aide E did not report the late administration. Additionally, the facility did not provide a policy for timely medication administration, only a policy titled Documentation of Medication Administration, which did not address the timeliness of medication administration.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during a survey. On one occasion, a Licensed Vocational Nurse (LVN) left a medication cart unsupervised and unlocked for seven minutes while attending to a resident, leaving the cart out of her line of sight. This lapse in security could potentially allow unauthorized access to medications, posing a risk to resident safety. Additionally, the facility was found to have expired insulins stored in the medication cart for three residents. Resident #5's liraglutide pen was expired by 19 days and stored unrefrigerated. Resident #81 had three vials of insulin lispro, which were unlabeled with expiration dates and expired by up to 59 days. Resident #85's insulin lispro vial was expired by 45 days. These expired medications were available for administration, which could compromise the therapeutic effects intended for the residents. The facility's policy on medication labeling and storage was not adhered to, as evidenced by the improper storage and labeling of medications. The Director of Nursing (DON) confirmed that the expectation was for medication carts to be locked when unattended, and it was the responsibility of individual nurses to ensure this. The facility's policy also required medications to be stored under proper temperature controls and labeled with necessary information, including expiration dates, which was not followed in these instances.
Food Safety and Documentation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was found that two bags of salad and a bag of ham in the refrigerator were not properly labeled with discard dates. The Certified Dietary Manager (CDM) admitted to being unaware of who was responsible for this oversight and subsequently discarded the items to ensure food safety. This lack of proper labeling could potentially lead to food-borne illnesses among residents consuming meals prepared in the facility. Additionally, the facility's documentation for the Three Compartment Sink Log and Milk Refrigerator Temperature Log showed no recorded entries for several days in January. The CDM acknowledged the importance of these logs in maintaining food safety and expressed concern over the missing entries, which could compromise the effectiveness of dishwashing and temperature control processes. The absence of these records indicates a failure to consistently monitor and document critical food safety measures. Furthermore, a dietary aide was observed with a facial piercing and improperly covered hair while working in the kitchen, which violates the facility's dress code policy. The CDM recognized the need for staff training on dress code compliance to prevent contamination risks. The Registered Dietitian (RD) emphasized the importance of labeling and dating food products and maintaining accurate logs to prevent food-borne illnesses, aligning with the facility's policies and the U.S. Food and Drug Administration's Food Code.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with Enhanced Barrier Precautions (EBP) for residents requiring such measures. Resident #69, diagnosed with a urinary tract infection (UTI) and assessed with the need for EBP, was involved in two separate incidents. On one occasion, the Director of Nursing (DON) attempted to administer intravenous access while wearing only one glove as personal protective equipment (PPE), despite the presence of EBP signage and PPE supplies at the room entry. In another instance, Medication Aide E administered medication to Resident #69 without wearing any PPE, acknowledging the oversight despite the clear requirement for EBP. Additionally, Resident #45, who was prescribed a gastric tube and assessed with a need for EBP, was involved in an incident where Licensed Vocational Nurse J administered medications via the g-tube while wearing gloves but not a gown, contrary to the EBP protocol. The room had appropriate EBP signage and PPE supplies, yet the nurse admitted to forgetting to wear the gown. These failures in adhering to infection control protocols could potentially lead to cross-contamination and infections among residents.
Deficiencies in Secured Backyard and Smoking Patio Area
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the secured backyard and smoking patio area. Observations from January 26 to January 30, 2025, revealed a section of chain link fencing was detached from the top rail and leaning down, posing a potential risk for resident elopement. Additionally, several red fire-rated trash cans designated for cigarette butts were filled with non-cigarette butt trash, and a regular trash can contained both trash and cigarette butts, creating a potential fire hazard. Resident #24, who was assessed as an elopement and wander risk, was observed in the smoking patio area. This resident had a history of tobacco use, lack of coordination, and muscle weakness, and was supported for safety with a wander guard anklet. The care plan for Resident #24 included monitoring for elopement and smoking-related injuries. Resident #55, with severe cognitive impairment and a history of behavioral disturbances, was also present in the area. Resident #83, with severely impaired cognition and a history of behavioral symptoms, was another resident observed in the smoking patio. Interviews with facility staff, including the Admissions Coordinator and the Operations Manager, revealed a lack of awareness and oversight regarding the condition of the secured backyard and smoking patio. The facility's smoking policy required metal containers with self-closing covers in smoking areas and specified that ashtrays should be emptied only into designated receptacles. However, the facility failed to adhere to these policies, as evidenced by the improper use of trash cans and the detached fencing, which were not addressed by the staff.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by the late administration of medications to several residents. Medication Aide E was observed administering medications late to multiple residents, including those with conditions such as vascular dementia, seizures, hypertension, schizophrenia, epilepsy, GERD, constipation, muscle weakness, diabetes, and urinary tract infections. The medications were administered beyond the prescribed time window, with delays ranging from 20 minutes to nearly two hours. This failure to administer medications on time was acknowledged by Medication Aide E, who did not report the delays to her direct supervisor, the Director of Nursing (DON). Additionally, the facility was found to have expired insulins stored in the medication cart, which were available for administration to residents. Insulin vials and pen injectors for residents with diabetes were stored unrefrigerated and were past their expiration dates, with some being expired by as much as 59 days. The insulins were not labeled with expiration dates, and the staff could not confirm the intended recipients or the dates the vials were unrefrigerated. This practice placed residents at risk of not receiving the therapeutic effects of their prescribed medications. The facility's policies on medication administration and storage were not adequately followed, as evidenced by the lack of timely administration and improper storage of medications. The DON stated that medications should be administered within one hour of the prescribed time and that expired or unlabeled insulins should be discarded. However, the facility did not provide a policy for timely medication administration, and the existing policies on medication labeling and storage were not adhered to, leading to the deficiencies observed.
Privacy and Confidentiality Breach by LVNs
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as evidenced by two specific incidents involving Licensed Vocational Nurses (LVNs). In the first incident, LVN J was observed entering two different residents' rooms without knocking, which is a violation of the facility's policy that requires staff to knock and request permission before entering a resident's room. During an interview, LVN J acknowledged the oversight and admitted to not knocking on the doors before entering. In the second incident, LVN Z left a computer screen open, displaying a resident's personal information, including their picture, name, vitals, age, ID number, and medications. This occurred while LVN Z was busy checking resident lunch trays, and she admitted to forgetting to turn off the monitor. The facility's policy on confidentiality mandates that access to resident personal and medical records be limited to authorized staff, and this incident represents a breach of that policy.
Inadequate Lighting in Dining Room Affects Residents' Well-being
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, specifically in the dining room area where adequate lighting was not maintained. Observations revealed that several fluorescent lamps and fixtures were malfunctioning, resulting in dim lighting conditions. This issue persisted over several days, from January 26 to January 30, 2025, despite attempts by staff to rectify the situation. The malfunctioning lights were noted to flicker and intermittently fail, causing discomfort and dissatisfaction among the residents. Two residents, both with intact cognition and complex medical conditions, expressed their dissatisfaction with the lighting conditions. One resident, who had a history of dysphagia, anxiety, and bipolar disorder, reported feeling lonely and isolated, while the other resident, diagnosed with bilateral cataracts and depression, expressed feelings of being down due to the dim lighting. Both residents indicated that the poor lighting affected their ability to see their food during meals, which could potentially impact their nutritional intake and overall well-being.
Discrepancy in Resident's Code Status in Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which is consistent with the resident's rights and includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, there was a discrepancy between the resident's code status as documented in the care plan and the resident's wishes. The resident's care plan indicated a Do Not Resuscitate (DNR) status, while the resident expressed a desire to be a Full Code, and the physician orders also reflected a Full Code status. The deficiency was identified through interviews and record reviews, revealing that the resident's care plan did not match the physician orders or the resident's stated wishes. The social worker confirmed the inconsistency and acknowledged the need to verify and update the resident's code status upon admission and during quarterly assessments. This failure could potentially affect the resident by not having their end-of-life preferences met, as the care plan did not accurately reflect the resident's current wishes and medical orders.
Failure to Ensure Functioning Wander Guard for Resident
Penalty
Summary
The facility failed to ensure that Resident #84's wander guard was functioning properly, which is a device intended to prevent elopement. The resident, who has a history of falling, cognitive communication deficit, and is considered an elopement risk, was observed exiting through a door without triggering the alarm. This incident occurred despite the presence of staff members both inside and outside the exit door. The wander guard was supposed to be checked daily, but it was found not to be working during the survey period. Interviews with staff, including the Director of Nursing (DON) and a Certified Nursing Assistant (CNA), revealed that the wander guard was not functioning between specific dates, but the exact date it stopped working was unknown. The DON admitted that the wander guard might have stopped working overnight and emphasized the importance of these devices in keeping residents safe. The CNA confirmed that the wander guard was not checked properly, as it was not functioning when tested at multiple doors. The facility's documentation indicated that wander guards should be checked for proper function and documented in the electronic medical administration record (eMAR).
Failure to Maintain Nutritional Status Leads to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to a significant weight loss. The resident, who had a history of depression, vitamin deficiencies, dysphagia, and a stage 3 pressure ulcer, experienced a weight loss of 11.9 pounds in six days and 10 pounds over one month. Despite the care plan indicating the need for weekly weights and nutritional assessments, the facility did not conduct these assessments in December 2024 or January 2025. The resident expressed a desire to maintain a weight of 205 pounds, but the facility did not follow through with the necessary interventions to address the weight loss. Interviews revealed that the facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Dietitian (RD), were aware of the resident's weight loss but did not implement timely nutritional interventions. The RD acknowledged the significant weight loss and the need for extra protein and calories for wound healing but admitted that no significant weight note was made. The facility's policy required weight assessments and interventions for significant weight loss, but these were not adequately followed, resulting in a lack of appropriate care planning and intervention for the resident's nutritional needs.
Failure to Follow Prescribed Diet Textures
Penalty
Summary
The facility failed to adhere to the prescribed dietary menus for residents on soft bite-sized and minced moist diets during a dinner meal. Specifically, the menu for the dinner included Tomato Basil Soup and Pimento Cheese Sandwich, which required specific preparation methods to meet the dietary needs of residents. However, the facility served a full pimento cheese sandwich and non-pureed tomato basil soup, contrary to the required minced and moist and soft bite-sized textures. This discrepancy was observed during a meal tray inspection, and it was confirmed that the recipes were not followed as per the dietary requirements. Interviews with staff revealed a lack of adherence to the dietary guidelines and a gap in knowledge regarding the preparation of these specific diet textures. The RN overseeing meal trays acknowledged the oversight, and the CDM admitted to not pureeing the soup or grinding the sandwich as required. The RD highlighted the risk of choking hazards if residents received incorrect diet textures and noted that training on these textures had been conducted six months prior, but acknowledged the need for further in-service training due to staff turnover. The DON emphasized the importance of serving diets as prescribed to prevent choking hazards, but could not recall the timing of the last training session.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for two residents identified as elopement risks. One resident, diagnosed with vascular dementia, epilepsy, and other cognitive impairments, was supposed to be monitored with a wander guard and regular checks. However, on one occasion, the resident removed the wander guard and eloped from the facility, reaching a bus station before being found and returned by staff. The resident's care plan included interventions such as visual checks and electronic monitoring of the wander guard, but these measures were insufficient to prevent the elopement. Another resident, with a history of Alzheimer's disease and dementia, was also identified as an elopement risk and was supposed to be engaged in structured activities to distract from wandering. Despite these interventions, the resident eloped from the facility and was found down the street in front of a church. The resident was exposed to high temperatures and was later diagnosed with heat exhaustion. The care plan for this resident included wearing a wander guard and participating in structured activities, but these interventions failed to prevent the elopement. The facility's policy on wandering and elopement required staff to monitor residents at risk and respond promptly to alarms. However, the incidents indicate a failure in implementing these policies effectively. Staff interviews revealed uncertainty about how the residents managed to elope, suggesting lapses in supervision and monitoring. The facility's inability to prevent these elopements placed the residents at risk of harm, highlighting deficiencies in the facility's safety protocols and supervision measures.
Unlicensed Administrator Appointment
Penalty
Summary
The facility's governing body failed to designate a person to exercise the administrator's authority when the facility did not have a licensed administrator. The facility terminated Licensed Administrator A on November 8, 2024, and subsequently hired Employee B, who was not a licensed administrator, 24 days later. Employee B served in the capacity of the administrator for 39 days without the necessary licensure. During this period, Employee B was listed as the Administrator in the facility's records, despite not having a Nursing Home Administrator (NHA) license, which was a requirement for the position. Employee B had previously worked as an Administrator in Training (AIT) and was in the process of obtaining her NHA license, with authorization to register for the exam received on December 11, 2024. However, she was not yet licensed at the time of her appointment. Administrator C, who was licensed but affiliated with another facility, was present only once or twice a week to oversee Employee B's activities. The South Texas President acknowledged the 30-day grace period to fill the administrator position and was aware of Employee B's unlicensed status, but believed she was a suitable fit for the facility. This oversight could potentially result in a decrease in the quality of care provided to the residents, although no immediate harm was reported.
Failure to Investigate Resident Altercation
Penalty
Summary
The facility failed to maintain documentation of a thorough investigation into an alleged violation involving a resident-to-resident altercation. The incident involved a 56-year-old male resident with a history of epilepsy, encephalopathy, opioid abuse, bipolar disorder, alcohol abuse, and blindness in one eye, who threw a cup at a 64-year-old male resident with diagnoses including diabetes with neuropathy, bipolar disorder, major depressive disorder, and hypertension. The altercation occurred when the first resident felt threatened during an argument with his roommate over cleanliness, leading to the cup being thrown. Despite staff intervention and the subsequent relocation of the resident, the facility did not document a proper investigation into the incident. The former administrator failed to investigate the altercation, and the current administrator in training (AIT) was unable to locate the required Potential Incident Report (PIR) for the incident. The AIT, who joined the facility after the incident, made several attempts to contact the former administrator for information but received no response. The facility's policy requires all possible incidents of abuse, neglect, or mistreatment to be identified and investigated, but this was not adhered to in this case. The lack of documentation and investigation could place residents at risk for further abuse from altercations.
Failure to Conduct Proper Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate pre- and post-dialysis assessments, consistent with professional standards of practice. Specifically, the resident did not have a complete set of vital signs assessed prior to leaving for dialysis on eight occasions and upon returning from dialysis on nine occasions. The resident's care plan indicated the need for dialysis and the importance of assessing the dialysis access site for any redness, swelling, or pain. However, the facility's records showed that the necessary pre- and post-dialysis evaluations were not completed on multiple dates, with vital signs from previous dates being documented instead. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed that the facility's protocol required residents to be assessed on the same day of dialysis, both before leaving for and after returning from the dialysis center. These assessments were crucial to determine the resident's stability and included checking vital signs and the dialysis access site. The DON was unaware that assessments from previous dates were used, as she only reviewed assessments triggered by abnormal results. Attempts to interview the Licensed Vocational Nurse (LVN) responsible for the assessments were unsuccessful.
Inadequate Hand Hygiene Practices in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during skin assessments and wound care for several residents. Observations revealed that LVN G did not adhere to the recommended handwashing duration, washing hands for significantly less than the required 20 seconds. Additionally, LVN G did not allow alcohol-based hand rub (ABHR) to dry before donning gloves, which is crucial for effective infection control. Resident #2, who had cellulitis and open lesions, was subjected to wound care where LVN G washed her hands for only 9 seconds before and 7 seconds after the procedure. During the wound care, LVN G also failed to allow the ABHR to dry before putting on new gloves, increasing the risk of infection transmission. Similar lapses were observed during skin assessments for Residents #5, #6, #8, #10, and #11, where handwashing durations were consistently below the recommended time. Resident #15, who had a pressure ulcer, also received wound care under similar conditions where LVN G did not allow the ABHR to dry before donning gloves. Interviews with staff, including LVN G, RN H, and the DON, highlighted a misunderstanding of the correct hand hygiene procedures, despite the facility's policy and CDC guidelines emphasizing the importance of proper hand hygiene to prevent infection. The facility's failure to ensure adherence to these guidelines compromised the safety and health of the residents.
Failure to Notify of Wound Changes Leads to Unstageable Pressure Ulcer
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident representative when there was a significant change in the resident's condition. This deficiency was identified in the case of a resident who experienced a change in the condition of a wound, which progressed to an unstageable pressure ulcer. The facility did not notify the wound care physician, primary care physician, or the resident's representative about the changes in the wound, which included the development of slough and eschar. The resident, who had a history of diabetes mellitus, end-stage renal disease, and hypertension, was at risk for developing pressure ulcers. Despite having a care plan in place to monitor and manage skin integrity, the facility failed to adhere to the plan's interventions, such as notifying the physician of significant findings and changes in the wound. The wound care physician was not informed of the necrotic tissue and slough, which were significant changes that required immediate attention and possible debridement. Interviews with facility staff revealed a lack of documentation and communication regarding the resident's wound changes. The treatment nurse admitted to not documenting notifications to the wound care physician and failing to notify the primary physician of the wound's progression. The wound care physician confirmed that they were not informed of the wound's deterioration, which was evident upon the resident's admission to the hospital, where the wound was found to be unstageable with necrotic tissue and infection.
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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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