Shady Acres Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newton, Texas.
- Location
- 405 Shady Acres Lane, Newton, Texas 75966
- CMS Provider Number
- 676055
- Inspections on file
- 39
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 14 (4 serious)
Citation history
Health deficiencies cited at Shady Acres Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide RN coverage for 8 consecutive hours daily and failed to maintain a full-time RN DON. Payroll review showed multiple days with no RN services, and interviews confirmed gaps in DON coverage after successive resignations. The HR Director, ADON, and Administrator all acknowledged periods when neither an RN nor a DON was present, while the facility continued interviewing for the DON role.
Kitchen sanitation and staff hygiene deficiencies were observed when the Dietary Supervisor and a Dietary Aide/Cook worked without beard restraints, a bug-filled fly tape was hanging near refrigerator B, the kitchen floors were sticky with debris, refrigerator A had fuzzy green spots on a wire rack, and the ice machine had lime buildup inside and out. Interviews showed staff knew beard restraints were required and that the ice machine had not been cleaned on a known schedule.
A resident with HTN and severe cognitive impairment was ordered two BP medications with hold parameters, but an LVN administered both meds on multiple occasions when the resident’s BP was outside the prescribed limits. The LVN said it was a careless mistake and acknowledged the meds should have been held as ordered; the ADON and Administrator stated meds were expected to be given according to physician orders.
Loose Unidentified Pills Found in Medication Cart Drawers: The Hall D and Hall C med carts were observed in use while the QA nurse was giving meds from them, and each cart had loose unidentified pills in the 2nd drawer. Hall D contained 18 whole and 5 broken pills, and Hall C contained 5 whole and 1 broken pill. The QA nurse, ADON, and Administrator stated the loose meds had been overlooked, and the facility policy required drugs and biologicals to be stored in a safe, secure, orderly manner in their original packaging.
Failure to use PPE during ADL care for a resident on EBP. A resident with dysphagia, severe cognitive impairment, and a feeding tube was observed receiving peri-care and brief care without a gown, even though EBP signage and PPE were present at the room entrance. Two CNAs acknowledged they knew the resident was on EBP but forgot to don a gown, and both staff members’ uniform clothes touched the resident’s gown and bed linens during care.
Two residents were not protected from sexual abuse when a male resident, with no prior documented history of sexual behaviors, inappropriately touched one female resident's breast and genital area and touched another female resident's breast without consent. Both female residents had cognitive impairments and reported the incidents to staff, with no physical injuries found. The incidents were categorized as abuse, and the male resident later admitted to inappropriate behaviors during a behavioral hospital stay.
The facility did not submit investigation results for three separate incidents of alleged abuse and injury of unknown origin to the State Survey Agency within the required 5-day period. Although investigations were completed and documented in the electronic medical record, the responsible staff member failed to manually upload the reports to the state system, resulting in delayed reporting for incidents involving two residents with allegations of inappropriate touching and one resident with an unexplained injury.
Multiple residents with severe cognitive impairments and behavioral health diagnoses were involved in repeated incidents of sexual, physical, and verbal abuse, including inappropriate sexual contact, physical aggression, and threats. Staff intervened in some cases but did not consistently update care plans, report incidents to the abuse coordinator, or ensure adequate supervision, resulting in a pattern of unaddressed abuse and neglect.
Multiple incidents of physical, verbal, and sexual aggression between residents, as well as an incident of neglect, were not reported by staff to the abuse coordinator or State Agency within required timeframes. Staff failed to follow established procedures for immediate and timely reporting after witnessing or being informed of abuse or neglect, despite residents' significant cognitive impairments and behavioral histories. Care plans were not updated to reflect new or ongoing aggressive or sexual behaviors following these events.
The facility did not consistently update or revise care plans for several residents following incidents of aggression, abuse, or significant behavioral changes. For example, a resident with severe cognitive impairment and behavioral issues repeatedly engaged in inappropriate sexual and aggressive behaviors without timely care plan updates, while other residents who experienced or exhibited aggression did not have their care plans revised to address safety or new interventions. Staff interviews confirmed that care plan updates were delayed due to workload and staffing issues, and required policy timelines for care plan development and revision were not met.
The facility failed to maintain clean oxygen concentrator filters for three residents requiring respiratory care. A resident with COPD, another with lung cancer and congestive heart failure, and a third with acute respiratory failure were all found with concentrators covered in dust and lacking proper filter maintenance. Staff interviews revealed confusion over responsibility for cleaning, leading to oversight and potential risk of decreased airflow.
A gas stove burner in the facility's kitchen failed to light, as observed during a survey. The Dietary Manager and Maintenance Director were responsible for ensuring equipment functionality, with staff trained to report malfunctions. The Maintenance Director identified a potential grease clog in the pilot nozzle and ordered a replacement part. The Administrator confirmed that all burners were operational during his last inspection.
A facility failed to accurately assess a resident's medical needs, resulting in incorrect MDS coding for insulin use. The resident, who had no diabetes diagnosis or insulin orders, was mistakenly recorded as receiving insulin injections. Staff interviews confirmed the error, which was acknowledged by the ADON responsible for the MDS. The DON noted that such inaccuracies could lead to inappropriate care.
A facility failed to maintain an effective infection control program, as a resident's pleural drain bag was found on the floor, contrary to care plan directives. The resident, with lung cancer and memory issues, was dependent on ADLs. Staff interviews confirmed the drain bag should not be on the floor to prevent infection, but the facility lacked a formal policy for handling pleural drain bags.
A resident at high risk for falls, with Alzheimer's and Parkinson's, experienced an unwitnessed fall resulting in a laceration above her eye due to the absence of a fall mat. The care plan did not include a fall mat as an intervention, and staff oversight led to the mat not being placed by the bed. Facility policies on safety and fall risk management were not followed.
A resident with dementia and schizophrenia was verbally abused by a CNA, who made intimidating remarks while attempting to get the resident out of bed. The Administrator overheard the incident and confirmed the CNA's inappropriate behavior. Despite prior training on abuse prevention, the CNA admitted to raising her voice due to personal stress. The resident required supervision and assistance with ADLs and had behavioral issues, which may have contributed to the situation.
A resident with Alzheimer's and a history of falls experienced a witnessed fall in the lounge area, resulting in a right hip fracture. The facility reported the incident as neglect to TULIP but did not conduct a thorough investigation or submit a 5-day report, believing the incident was not reportable. The QA LVN and Administrator attempted to delete the report but did not confirm its removal, failing to adhere to the facility's policy on reporting and investigation.
A resident with Alzheimer's, dementia, and Parkinson's was at high risk for falls, but the facility failed to include a fall mat in her care plan. This oversight led to two incidents where the resident sustained injuries from falls. Staff interviews confirmed the care plan should have included a fall mat, and the facility's policies emphasized the need for specific interventions to reduce accident risks.
A facility failed to provide adequate supervision and safety measures for residents who smoke, resulting in a serious incident where a resident on oxygen therapy sustained burns after her oxygen caught fire. The incident involved two other residents who were smoking in a non-designated area without supervision. Staff were unaware of residents' smoking statuses and failed to enforce policies regarding smoking materials, contributing to the unsafe conditions.
A resident using oxygen sustained burns after smoking in a non-designated area with two other residents. The facility failed to supervise the residents, allowed smoking materials in rooms, and did not reassess smoking safety. Staff were unaware of smoking policies, contributing to the incident.
The facility failed to implement comprehensive care plans for three residents regarding smoking safety. One resident with severe cognitive impairment was observed smoking while on oxygen without a care plan addressing smoking safety. Another resident, cognitively intact, did not comply with the smoking policy and kept smoking supplies in his room, while a third resident's care plan was not updated after being found with cigarettes. Staff were unaware of residents' smoking habits and supervision needs, increasing the risk of unsafe smoking practices.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to utilize the services of an RN for 8 consecutive hours a day, 7 days a week, and failed to designate an RN as the DON on a full-time basis. Review of RN payroll hours for 01/01/26 through 04/29/26 showed no RN services on 20 dates in January, February, March, and April 2026. The facility also had periods without a DON after the prior DON resigned on 02/18/26, with the HR Director stating there were 6 days in February without a DON, 16 days in March without a DON after another DON resigned on 03/04/26, and 8 days in April without a DON after the next DON resigned on 04/20/26. During interview, the HR Director stated the facility had not hired a full-time DON after the resignations and that the Administrator was responsible for ensuring daily RN coverage and hiring a DON. The HR Director said the facility had been interviewing candidates but had not hired anyone. The ADON, who is an LVN, stated that at times there was neither an RN nor a DON present and that she would seek guidance from a DON at another facility, physicians, Nurse Practitioner, pharmacy, or dietitian when needed. She also stated that having an RN and DON was important because they provided oversight, guidance, and more in-depth assessment when needed. The Administrator acknowledged that the facility did not have RN coverage or an acting DON and stated he expected the facility to have an RN working eight consecutive hours every day and to have an acting or full-time DON. He said the previous DON resigned without notice, the facility had been advertising for the DON position, and there was no corporate RN or regional RN to assist until one was hired. Record review of incidents and accidents for January through April 2026 did not reveal any negative outcomes related to the lack of RN services or DON coverage. The facility policy stated the Nursing Services department is under the direct supervision of an RN and that the DON is a registered nurse employed full-time 40 hours per week.
Kitchen sanitation and staff hygiene deficiencies
Penalty
Summary
Food service safety deficiencies were identified in the kitchen during observation, interview, and record review. The Dietary Supervisor and Dietary Aide/Cook C were observed without beard restraints while working in the kitchen, even though both acknowledged they should have worn them to prevent hair from getting into residents’ food. The Administrator also stated that all staff with beards of any length should wear beard restraints. The kitchen environment was observed to be unsanitary in several areas. A long brown fly tape hanging from the ceiling was located approximately 12 inches from refrigerator B and was filled with bugs. The floors in the kitchen had debris and were sticky throughout. Inside refrigerator A, small fuzzy green spots were observed on the wire rack. There was also lime buildup on the outside and inside of the ice machine. During interviews, the Dietary Supervisor said the floors were mopped daily multiple times a day but the sticky substance could not be removed unless boiling hot water was used. He also said he did not know when the ice machine was last drained and cleaned and did not have a person designated to clean it. The Dietary Aide/Cook C said he was responsible for daily cleaning of the kitchen, including the refrigerator and ice machine, after meal services, but did not know when the ice machine was last drained and cleaned and said it had been a while. The Administrator stated the bug tape should not have been in the kitchen and that the Dietary Supervisor was responsible for overseeing daily and after-meal cleaning of the kitchen and ice machine.
Failure to Hold Blood Pressure Medications per Ordered Parameters
Penalty
Summary
Resident #3, a cognitively severely impaired male with a diagnosis of hypertension, was ordered Lisinopril 10 mg daily to be held if systolic blood pressure was less than 110 or diastolic blood pressure was less than 60, and Metoprolol tartrate 25 mg twice daily to be held if systolic blood pressure was less than 100, diastolic blood pressure was less than 60, or heart rate was less than 60. Review of the April 2026 MAR showed that LVN A administered both blood pressure medications on multiple occasions when the resident’s vital signs were outside the ordered parameters. The medications were given on several dates when the recorded blood pressure did not meet the physician’s hold instructions, including readings of 100/56, 115/57, 103/53, 108/52, and 107/52. During interview, LVN A stated it was a careless mistake and acknowledged the medications should have been held as ordered. The ADON and Administrator stated their expectations were that medications be administered according to physician orders, including parameters. The facility policy stated medications are to be administered in accordance with prescriber orders, including required time frames.
Loose Unidentified Pills Found in Medication Cart Drawers
Penalty
Summary
The facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 2 of 3 medication carts observed, specifically the Hall D and Hall C medication carts. During an observation and interview on 04/28/2026 at 2:25 p.m., the QA nurse stated she was giving patient medication from the Hall D medication cart that day, and the 2nd drawer contained 18 whole and 5 broken loose unidentified pills. She said the medication cart should be cleaned and no loose pills should be in the drawers. During an observation and interview later that day at 2:39 p.m., the Hall C medication cart was also reviewed with the QA nurse, who said she was giving patient medication from that cart that day. The 2nd drawer contained 5 whole and 1 broken loose unidentified pill. The QA nurse, ADON, and Administrator each stated that the nurses giving medication from the carts were responsible for keeping them free of loose pills, and that the loose medication had been overlooked. A facility policy revised April 2019 stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner, in the packaging or dispensing systems in which they are received, and that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Use PPE During ADL Care for Resident on EBP
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 1 of 5 residents reviewed for infection control. Resident #5 was a [AGE]-year-old male admitted with dysphagia, had a BIMS score of 03 on the quarterly MDS indicating severe cognitive impairment, and had a feeding tube included in his nutritional approaches. His care plan stated that he required tube feeding and was dependent with tube feeding and water flushes, and his April 2026 physician orders indicated a tube feeding only diet. During an observation, Resident #5 had Enhanced Barrier Precaution signage in place and PPE was available at the room entrance, but CNA E entered the room to provide ADL care without donning a gown. While CNA E cleaned the resident’s peri-area and changed his brief, CNA F entered and assisted with pulling the resident up in bed. During this care, both CNAs’ bare uniform clothes touched the resident’s gown and bed linens. In interviews, both CNAs stated they knew the resident was on Enhanced Barrier Precaution but forgot to put on a gown. The ADON stated that a resident with a gastrostomy tube was on Enhanced Barrier Precaution and staff should wear a gown and gloves while providing care, and the Administrator stated staff had been trained and retrained on EBP and that the failures violated infection prevention and control requirements.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that two residents were free from sexual abuse, resulting in a deficiency related to resident rights and protection from abuse. One male resident, who was cognitively intact and had diagnoses including mood disorder, dementia, and anxiety disorder, entered the room of a female resident and inappropriately touched her breast and genital area. The female resident, who was moderately cognitively impaired with diagnoses including spina bifida, anxiety disorder, and diabetes, reported the incident to staff. The incident was not witnessed, and the resident stated she told the staff the next day. The male resident denied the allegations at the time, and there was no prior documented history of sexual behaviors for him in the facility before this incident. A second female resident, who had a history of stroke, aphasia, anxiety disorder, and diabetes, reported to staff that the same male resident had touched her breast without consent on an unidentified date. This resident was also moderately cognitively impaired and had difficulty communicating due to her medical condition. The incident was reported after the resident became withdrawn and stopped participating in activities, which was noticed by the activity director. Upon questioning, the resident indicated she had been touched inappropriately. The male resident was already under increased monitoring at the time this second allegation was reported. Both incidents were categorized as abuse, and assessments conducted by nursing staff found no physical injuries to either female resident. The facility's records indicate that staff were able to identify abuse reporting procedures and immediate intervention steps, but the deficiency occurred due to the failure to prevent the male resident from accessing and inappropriately touching the female residents. The male resident later admitted to inappropriate behaviors during a behavioral hospital stay, but continued to deny the allegations to facility staff. There was no documentation of prior sexual behavior history for the male resident before these incidents.
Failure to Timely Report Investigation Results of Abuse and Injury Allegations
Penalty
Summary
The facility failed to report the results of all investigations of alleged abuse, neglect, or injury of unknown origin to the administrator or designated representative and to the State Survey Agency within 5 working days, as required by regulation and facility policy. Specifically, for three separate incidents involving allegations of inappropriate touching and an injury of unknown origin, the Provider Investigation Reports (Form 3613-A) were completed in the facility's electronic medical record system but were not submitted to the Texas Unified Licensure Information Portal (TULIP) within the required timeframe. The Assistant Director of Nursing (ADON), who was responsible for submitting these reports, believed the electronic system would automatically upload the reports, but later realized manual submission was necessary. The first two incidents involved a male resident with diagnoses including mood disorder, dementia, and high risk of heterosexual behaviors, who was alleged to have inappropriately touched two female residents. Both female residents had significant cognitive or physical impairments, including spina bifida, anxiety disorder, depressive episodes, diabetes, stroke, and aphasia. Immediate actions were taken by administration and clinical staff, and thorough investigations were completed, but the results were not timely reported to the State Survey Agency as required. The third incident involved a female resident with Alzheimer's disease, Parkinson's disease, and severe cognitive impairment, who sustained an injury of unknown origin resulting in a hip fracture and other medical complications. Although the investigation was completed and documented, the results were not uploaded to the TULIP system within the mandated 5-day period. Interviews with the ADON and Administrator confirmed the oversight and misunderstanding regarding the submission process, which led to the deficiency.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse and neglect, as evidenced by several incidents involving both sexual and physical abuse among residents. In one instance, a female resident with severe cognitive impairment and a history of traumatic brain injury was observed with her hand down the pants of a male resident, who was also severely cognitively impaired and diagnosed with schizophrenia and impulse disorder. The male resident held the female resident's hand in place and resisted staff intervention, requiring nursing staff to manually remove her hand. The care plans for both residents did not reflect updates or interventions addressing these sexual behaviors, despite prior incidents of inappropriate sexual conduct by the male resident, including exposing himself and masturbating in common areas, as well as inappropriate physical contact with another female resident who was also severely cognitively impaired and unable to communicate effectively. Additional incidents involved physical and verbal aggression between residents. One resident, with Alzheimer's disease and major depressive disorder, exhibited repeated aggressive behaviors, including hitting another resident on the hand with silverware, throwing coffee, making verbal threats, and physically striking other residents. These behaviors were documented in progress notes, but care plans were not updated to address the ongoing aggression or to provide interventions for the victims. In several cases, staff intervened to separate residents and de-escalate situations, but there was no evidence that these incidents were consistently reported to the abuse coordinator or that care plans were revised to reflect the risks and necessary supervision. The report also details failures in communication and documentation, such as not reporting certain abuse allegations to the state agency in a timely manner and lacking evidence of consent or capacity to consent in cases of alleged consensual sexual contact between cognitively impaired residents. Interviews with staff and family members confirmed awareness of behavioral issues and incidents, but also revealed gaps in monitoring, reporting, and care planning. The cumulative effect of these actions and inactions resulted in an Immediate Jeopardy finding, as the facility did not ensure residents' right to be free from abuse and neglect, and failed to implement adequate supervision, assessment, and care plan updates in response to repeated incidents.
Failure to Timely Report Alleged Abuse, Neglect, and Sexual Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or theft were reported immediately to the abuse coordinator and, when required, to the State Agency within the mandated timeframes. Multiple incidents involving resident-to-resident physical and sexual aggression, as well as verbal abuse, were not reported as required. In several cases, staff did not notify the abuse coordinator immediately after witnessing or being informed of abuse allegations, and several incidents were not reported to the State Agency within the required two-hour window for abuse or bodily injury, or within 24 hours for neglect. These failures were identified for seven out of ten residents reviewed for abuse. Specific events included a resident throwing coffee and threatening another, resulting in a physical altercation; a resident verbally abusing another, with threats of physical harm; and multiple instances of physical aggression, such as a resident hitting another with silverware and punching another resident in the chest. There were also incidents of sexual abuse, including a resident placing a hand down another resident's pants and a resident rubbing his private area against another resident. In each of these cases, documentation showed that the incidents were either not reported to the abuse coordinator or not reported to the State Agency within the required timeframe. Additionally, an incident of neglect involving a resident's unwitnessed fall with injuries was not reported to the State Agency within 24 hours. The residents involved had significant cognitive impairments, including diagnoses of Alzheimer's disease, dementia, major depressive disorder, and schizophrenia. Many required supervision or assistance for daily activities and had documented histories of behavioral symptoms such as aggression, inattention, and disorganized thinking. Despite these known risks, the facility did not update care plans to reflect new or ongoing aggressive or sexual behaviors following these incidents, nor did staff consistently follow established procedures for reporting abuse, neglect, or theft as required by regulation.
Failure to Update and Implement Comprehensive Care Plans Following Resident Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. Specifically, care plans were not updated or revised to address significant changes in residents' conditions, including incidents of sexual and physical aggression, as well as abuse allegations. For example, one resident with schizophrenia, dementia, and impulse disorder exhibited repeated sexually inappropriate behaviors and aggression toward others, but the care plan was not updated to include interventions to prevent further incidents on several occasions. Another resident with Alzheimer's disease and major depressive disorder had multiple episodes of verbal and physical aggression toward other residents, including hitting and threatening, yet the care plan was not revised to reflect these behaviors or to implement new interventions after each incident. Several other residents who were victims of resident-to-resident aggression or abuse did not have their care plans updated to address their safety or to reflect the incidents they experienced. In one case, a resident was physically assaulted by another resident, but the care plan was not revised to include safety interventions. Another resident was subjected to inappropriate sexual behavior by a peer, but the care plan did not reflect this event or include measures to protect the resident. Additionally, a resident with significant cognitive impairment and multiple medical diagnoses was discharged before a comprehensive care plan was developed, despite the presence of a baseline care plan. Interviews with facility staff, including the ADON/MDS Coordinator, DON, and Administrator, revealed that care plan updates were delayed due to workload issues and staff covering multiple roles. Staff acknowledged that care plans should be individualized and revised promptly following incidents or changes in condition, but this was not consistently done. Facility policy required care plans to be developed within seven days of the MDS assessment and updated after significant changes, but these requirements were not met for several residents involved in incidents of aggression, abuse, or significant behavioral changes.
Removal Plan
- Care plans for residents 1 & 3 have been updated to include interventions to prevent abuse and manage behaviors by ADON/MDS nurse.
- ADON/MDS nurses have been in-serviced on when care plans are due and the importance of completing them in a timely manner by the Administrator.
- Administrator and DON will also monitor daily notifications from medical charting software for upcoming care plans due dates.
- MDS coordinator will submit weekly to DON and Administrator care plan list to indicate which care plans are due.
- DON has reviewed all care plans due dates and none are overdue.
- All residents had care plans reviewed by DON and after adjustments were made all care plans are now found to be accurate.
- All residents on secure unit were assessed by DON for injury and signs/symptoms of abuse and neglect.
- Care plan updates will be emailed by the ADON/MDS nurse to each nurses' station when a change occurs or a new focus is added such as but not limited to a change in behavior.
- The administrator will monitor for compliance by being copied on emails to nurse's stations.
- All charge nurses have been notified of this new system by DON.
- Nurses have been in-serviced by DON by cell phone on facility's policy and procedure for care plans and interventions.
- Staff were contacted and in-serviced by DON on abuse, neglect and exploitation, reporting suspected abuse, and intervention methods to include redirection.
- No staff will be allowed to work until this in-service is completed.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents who required oxygen management. Resident #1, a male with chronic obstructive pulmonary disease (COPD), was observed with an oxygen concentrator that lacked necessary air filters, and the areas meant to hold these filters were covered with a thick, dusty substance. This was despite his care plan indicating the need for oxygen at 2 liters per minute by nasal cannula when oxygen saturation fell below 92%. Resident #6, a female with lung cancer and congestive heart failure, was receiving oxygen at 4 liters per minute via nasal cannula. However, the filter on her oxygen concentrator was covered with a thick whitish substance. Interviews revealed confusion among staff about who was responsible for cleaning the filters, with the Maintenance Director believing it was the responsibility of the rental companies, and the ADON stating it should be done weekly by the night shift. Resident #39, a female with acute respiratory failure and heart failure, was also found with an oxygen concentrator filter covered in a thick, dusty substance. Despite her care plan requiring oxygen at 2 liters per minute as needed, the filters were not cleaned or replaced. Interviews with staff, including the DON and the Administrator, indicated that the responsibility for ensuring clean filters was not clearly assigned, leading to oversight and potential risk of decreased airflow to the concentrators.
Gas Stove Burner Malfunction in Kitchen
Penalty
Summary
The facility failed to maintain the gas stove in the kitchen in a safe operating condition, as observed on February 10, 2025, when one of the six burners did not light upon being turned on. The Dietary Manager (DM) noted that the burner had been functioning until that point and speculated that a pot might have splashed over, extinguishing the pilot light. The DM acknowledged responsibility for ensuring all kitchen equipment was operational and stated that staff were trained to report any equipment malfunctions to him or the Maintenance Director. The risk identified was that gas could escape if a knob was accidentally turned and the pilot light did not ignite immediately. Interviews with the Maintenance Director and the Administrator confirmed that the DM was primarily responsible for kitchen equipment maintenance, with the Maintenance Director serving as a backup. The Maintenance Director reported that all burners were functional during his last check on February 7, 2025, and suggested that grease might have clogged the pilot nozzle. He ordered a replacement part after being notified of the issue. The Administrator, who conducted weekly rounds, also confirmed that the burners were operational during his last inspection on February 2, 2025. Both the Maintenance Director and the Administrator emphasized the importance of staff reporting equipment issues promptly to ensure timely repairs.
Inaccurate MDS Coding for Insulin Use
Penalty
Summary
The facility failed to ensure accurate assessments for a resident, leading to an incorrect coding of the Minimum Data Set (MDS) for insulin use and injections. The resident, who was an elderly female with a history of hemiplegia, hypertension, and anxiety, did not have a diagnosis of diabetes mellitus nor any orders for insulin injections. Despite this, her quarterly MDS inaccurately indicated that she received insulin injections, which was not supported by her medical records or care plan. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON), confirmed that the resident had never received insulin or any type of injections. The ADON, who was responsible for completing the MDS, acknowledged the error and stated it would be corrected. The Director of Nursing (DON) also confirmed the incorrect coding and emphasized that such errors could lead to inappropriate resident care. The facility's policy on comprehensive assessments highlighted the importance of accurate coding to reflect the resident's clinical status, which was not adhered to in this case.
Inadequate Infection Control for Pleural Drain Bag
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper handling of a pleural drain bag for a resident with lung cancer, congestive heart failure, and high blood pressure. The resident, who had both long-term and short-term memory problems and was dependent on activities of daily living, was observed with their pleural drain bag and drain port on the floor under the bed. This observation was made despite the care plan indicating the need for enhanced barrier precautions related to the pleural drain. Interviews with facility staff, including an LVN, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that the pleural drain bag should not be on the floor to prevent infection and accidental dislodgement. The ADON, who also served as the infection control nurse, acknowledged the absence of a facility policy regarding the proper handling of pleural drain bags. The DON reiterated the expectation that the drain bag should be kept in a blue bag attached to the bed to prevent contamination. The lack of a formal policy and the improper placement of the drain bag on the floor represent a failure in the facility's infection control practices.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who was at high risk for falls. The resident, who had Alzheimer's, dementia, restless leg syndrome, and Parkinson's, experienced an unwitnessed fall resulting in a 3 cm laceration above her right eye. The incident occurred because the fall mat, which was supposed to be adjacent to her bed, was not in place at the time of the fall. The resident's care plan, which was supposed to include interventions to prevent falls, did not list a fall mat as an intervention despite the resident's high risk for falls. The care plan was not updated to include the fall mat even after a previous fall incident where the resident was found lying on her fall mat with a minor injury. Staff interviews revealed that there was a miscommunication and oversight in updating the care plan to include the fall mat. Staff members, including a CNA and LVN, acknowledged that the fall mat was moved away from the bed to facilitate the movement of the resident's Geri-chair and was not repositioned when the resident was transferred back to bed. The facility's policies on safety and supervision, as well as managing falls and fall risk, emphasize the importance of implementing and documenting interventions to reduce accident risks, which were not adhered to in this case.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). On the specified date, the Administrator overheard CNA F making intimidating remarks to a resident, instructing them to get up in a loud and inappropriate manner. The Administrator witnessed the incident and identified the CNA as the individual responsible for the verbal abuse. The resident involved in the incident was an elderly female with a history of dementia and schizophrenia, which affected her ability to make decisions and communicate effectively. Her care plan indicated she required supervision and assistance with activities of daily living (ADLs) and was dependent on staff for emotional and physical needs. The resident exhibited behavioral problems, including resistance to care, which may have contributed to the situation. The facility's investigation confirmed the verbal abuse incident, and the CNA involved had been trained on abuse prevention and resident rights. Despite this training, the CNA admitted to raising her voice due to having a bad day, although she denied using the specific language reported. The facility's records showed that the CNA was suspended and subsequently terminated following the incident.
Failure to Investigate and Report Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation and report the results of an incident involving a resident's fall within the required 5-day period. The resident, who had Alzheimer's, a right femur fracture, and a history of falling, experienced a fall in the lounge area. The fall was witnessed by staff, and the resident was subsequently sent to the emergency room for evaluation and treatment. Despite the incident being reported as neglect to the TULIP system, the facility did not complete an investigation or submit a 5-day report, as they believed the incident was not reportable due to it being witnessed. The Quality Assurance LVN and the Administrator both acknowledged that the report was made in error and attempted to have it deleted from the TULIP system. However, they did not follow up to ensure the report was actually removed. The facility's policy requires all reports of abuse, neglect, exploitation, or misappropriation to be thoroughly investigated and documented, but this was not adhered to in this case. The lack of investigation and reporting could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
Failure to Implement Comprehensive Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, who was at high risk for falls. The resident, diagnosed with Alzheimer's, dementia, restless leg syndrome, and Parkinson's, had a care plan that did not include the use of a fall mat, despite being at high risk for falls. This omission was evident in the care plan dated May 16, 2024, which listed several interventions but failed to mention the fall mat. The deficiency was highlighted by two incidents where the resident sustained injuries due to falls. On October 16, 2024, the resident was found lying on a fall mat with a small skin tear above her right eye, and on November 8, 2024, she was found on the floor with a 3 cm laceration above her right eye, requiring hospital treatment and sutures. Interviews with staff revealed that the fall mat was not consistently placed next to the resident's bed, contributing to the risk of injury. Interviews with facility staff, including the ADON, CNA, LVN, and the Administrator, confirmed that the care plan should have included a fall mat to prevent serious injuries. The staff acknowledged the oversight and the risk of serious injuries if fall mats were not in place. The facility's policies on safety, supervision, and care planning emphasized the importance of implementing and documenting specific interventions to reduce accident risks, which were not adhered to in this case.
Inadequate Supervision and Safety Measures for Smoking Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for residents who smoke, leading to a serious incident involving three residents. Resident #1, who was on oxygen therapy, was in a non-smoking area with Residents #2 and #3, both assessed as smokers. Resident #1's oxygen caught fire, resulting in multiple burns to her face, chest, and hands. The incident occurred because the residents were not in a designated smoking area, and there was no staff supervision present at the time. Resident #2 and Resident #3 were found to have kept smoking materials in their rooms, contrary to facility policy. Resident #2 was supposed to sign out his smoking supplies but did not comply, and staff were unaware of this non-compliance. Additionally, Resident #3 was not reassessed for smoking safety after the incident, and there was no updated Smoking-Safety Screen for either resident. The lack of proper assessments and supervision contributed to the unsafe conditions that led to the incident. Interviews with staff revealed a lack of awareness regarding which residents were smokers and who required supervision. There was no list of residents who smoked or required supervision, and staff were not consistently informed about residents' smoking statuses. This lack of communication and oversight resulted in residents smoking in non-designated areas without supervision, ultimately leading to the incident where Resident #1 sustained severe burns.
Failure to Ensure Smoking Safety Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to Federal, State, and Local laws and regulations regarding smoking safety, which resulted in a serious incident involving three residents. On the specified date, a resident who utilized oxygen was in a non-smoking area with two other residents who were assessed as smokers. The resident's oxygen caught on fire, leading to multiple burns on her face, chest, and hands. The facility did not ensure that the residents were smoking in a designated area, nor did they supervise the residents while they were smoking. Additionally, the facility failed to prevent residents from keeping smoking materials in their rooms. One resident admitted to keeping cigarettes and a lighter in his room, contrary to the facility's policy. The facility also did not reassess the residents for smoking safety after the incident, which was a critical oversight given the severity of the event. Interviews with staff revealed a lack of awareness regarding which residents were smokers and who required supervision, indicating a systemic failure in communication and policy enforcement. The incident highlighted the facility's inadequate smoking safety assessments and care planning. The residents involved had various medical conditions, including COPD and cognitive impairments, which should have necessitated stricter supervision and safety measures. The facility's failure to maintain up-to-date smoking safety assessments and care plans contributed to the unsafe environment that led to the incident.
Failure to Implement Comprehensive Smoking Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which included measurable objectives and timeframes to address their medical, nursing, mental, and psychosocial needs. Resident #1, a female with severe cognitive impairment and on oxygen therapy, did not have a care plan addressing tobacco use or smoking safety, despite being observed smoking a vape pen and attempting to smoke a cigarette while on oxygen. This oversight placed her at risk for unsafe smoking practices. Resident #2, a male with cognitive intactness, had a care plan for smoking that was not reviewed or updated when he refused to comply with the facility's smoking policy. He did not sign out to smoke off facility grounds and kept his smoking supplies in his room, contrary to the policy that required supervision and storage of smoking supplies at the nurses' station. The lack of updated assessments and care plans contributed to the staff's unawareness of his smoking habits and supervision needs. Resident #3, a female with cognitive intactness, had a care plan for smoking that was not updated after she was found with cigarettes and a lighter. Staff interviews revealed a lack of awareness regarding which residents smoked and their supervision requirements. The facility's failure to maintain a list of smokers and conduct regular smoking assessments led to inadequate supervision and increased the risk of unsafe smoking practices among residents.
Latest citations in Texas
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
