Shiner Nursing And Rehabilitation Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Shiner, Texas.
- Location
- 1213 N Ave B, Shiner, Texas 77984
- CMS Provider Number
- 675938
- Inspections on file
- 25
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Shiner Nursing And Rehabilitation Center Inc during CMS and state inspections, most recent first.
A dietary manager who was not a CDM served as the person overseeing food and nutrition services and was still in school for certification. During observation, she did not follow label directions for a whipped topping container and stored it in the refrigerator instead of the freezer. A resident with moderate cognitive impairment and recent significant wt loss received potato soup instead of the planned chicken and sausage gumbo, and the RD stated the substitution was not equivalent in protein and should have been documented on the substitution log.
Food preferences and diet orders were not consistently honored for two residents. One resident with cognitive impairment and recent wt loss was served loaded potato soup instead of the planned chicken and sausage gumbo, then later received fried foods despite documented dislikes and digestive intolerance. Another resident with dysphagia had a Negotiated Risk Agreement allowing regular foods, but her tray ticket still showed a mechanical soft diet, causing confusion when she requested a regular tray.
Kitchen Food Storage and Labeling Deficiencies: The kitchen had black circular spots inside the ice machine, whipped topping stored in the reach-in refrigerator without being frozen as indicated by the label, raw protein stored next to fully cooked food in the freezer, one food product without a name on its label, and 3 unlabeled buckets of food products. The DM and RD acknowledged the storage and labeling issues and discussed the risk of contamination and improper food identification.
A facility failed to maintain infection control during care for two residents. During incontinent care for one resident with dementia, diabetes, and bowel/bladder incontinence, a CNA did not sanitize between her fingers when using sanitizer between glove changes. During wound care for another resident with two pressure ulcers on EBP, an LVN did not don a gown, then changed gloves after cleaning the wound but did not sanitize her hands before applying treatment and dressing.
A resident with severe cognitive impairment and incontinence was observed receiving perineal care while CNAs attempted to use a privacy curtain that did not fully close around the bed, leaving the resident visible to the roommate and potentially anyone entering the room. In a separate incident, an unlocked laptop on a medication cart in a hallway displayed confidential resident information, and the MDS nurse confirmed it had been left unlocked accidentally.
A resident’s quarterly MDS failed to include his colon cancer diagnosis, even though hospital records showed invasive colonic adenocarcinoma and staff confirmed he returned to the facility with stage 4 colon cancer and was receiving chemo for palliative purposes. The diagnosis was also missing from the care plan, and the DON, ADM, MDS nurse, and reimbursement consultant all confirmed the omission.
The facility failed to keep care plans current for two residents. One resident’s care plan did not reflect colon cancer or chemotherapy after re-admission, even though staff knew he had stage 4 colon cancer and went for chemo. Another resident had dysphagia and a negotiated risk agreement to eat regular foods despite a mechanical soft order, but the care plan and tray ticket still reflected the mechanical soft diet, leading to confusion when she requested a regular meal.
Incomplete Perineal Care During Incontinent Care: A CNA provided incontinent care to a resident who was always incontinent of bladder and frequently incontinent of bowel, but did not clean the lower abdomen or groin areas. The resident had diagnoses including dementia, schizophrenia, type 2 DM, HTN, and CKD, and the care plan called for pericare after each incontinent episode. The CNA said she was nervous and forgot, while the DON stated staff should clean the lower abdomen and groin areas during incontinent care to help ensure proper cleaning and prevent infection.
The facility failed to ensure physician orders were signed and implemented for two residents. One resident had significant weight loss and an RD recommendation for fortified supplements and weekly weights that remained unsigned by the physician, while another resident’s pharmacy review recommending an increase in Januvia and discontinuation of sliding scale insulin was signed by the MD but not clarified or updated in the chart, leaving the order at the prior dose. Staff reported ongoing delays in getting MD responses and unsigned recommendations returned.
Unlocked Medication Cart in Hallway: Medication cart #1, located outside the dining room in the entrance hallway, was found unlocked when it was left unattended. An MDS nurse confirmed the cart was unlocked, and the ADM stated medication carts should be locked when left unattended. The cart contained narcotics in a separate locked container inside the cart.
A resident’s medical record was incomplete because his colon cancer diagnosis was not reflected on the admission record, MDS, or care plan, even though hospital records showed invasive colonic adenocarcinoma and staff knew he was going to chemotherapy. The resident said he had chemotherapy for colon cancer, and the MDS nurse, reimbursement consultant, DON, ADM, and CNAs all acknowledged the diagnosis and its impact on his condition were known but not documented in the key record sources.
Surveyors identified multiple deficiencies in food service sanitation and equipment maintenance, including leaking and soiled refrigeration units, an inoperable vent hood, stained kitchen floors, and unsanitary conditions such as rusty drying racks and dust-covered filters. Staff interviews confirmed that these issues had been ongoing and reported but not resolved, with the DON newly aware of the extent of the problems.
Surveyors found that the dining room's eight ceiling air conditioning vents were soiled with a black substance and rust, and the return vent was covered with dust. The Maintenance Director confirmed the vents had not been cleaned since the previous year, and there was no set cleaning schedule. Both the Maintenance Director and DON acknowledged the importance of keeping vents clean for residents and staff.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, over 42 days. This was due to staffing shortages and competition for nursing staff, as confirmed by interviews and record reviews. Efforts to fill shifts with interim staff and regional nurses were made, but a permanent solution was not secured.
The facility failed to ensure proper documentation of DNR orders for three residents, resulting in incomplete OOH DNR forms. A resident's form lacked the physician's printed name, while two others were missing required second signatures. These deficiencies could lead to confusion about the residents' end-of-life wishes.
The facility failed to maintain proper pharmaceutical services, including incomplete glucometer logs, expired supplies, and improper storage of loose pills. A resident with gastrointestinal issues did not receive the correct dose of omeprazole, and the administration of polyethylene glycol was inaccurately documented. These deficiencies highlight lapses in medication handling and administration procedures.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds, central ports, and indwelling catheters, as well as improperly stored clean items, posing a risk for infection spread. A resident with a draining wound, another with a central port, and a third with a catheter did not have EBP in place until after surveyor observations. Additionally, a name tag was found in a box of clean spoons on a medication cart, indicating improper storage practices.
A facility failed to implement a comprehensive care plan for a resident with a chronic wound, omitting enhanced barrier precautions (EBP) necessary to prevent infections. The resident, with Alzheimer's and other conditions, had a significant change in condition with a skin tear and a full-thickness wound. Despite a wound care order, there was no EBP order, and staff were observed not using PPE. The DON was unaware of the wound, indicating a lapse in communication and care planning.
A resident with a history of heart and vascular conditions did not receive knee-high compression socks as ordered, leading to swelling in her legs and feet. Despite the care plan and provider orders, the resident was observed without the prescribed socks on multiple occasions. Staff acknowledged the oversight and eventually located the socks in a locked storage area.
Two residents were found with potentially hazardous materials in their rooms, including medicated chest rub, hairspray, and beer, without staff knowledge or proper orders. One resident had moderate cognitive impairment, increasing the risk of misuse, while the other had intact cognition but was not monitored for alcohol use. The facility's policy prohibited such items without specific orders, and staff oversight was lacking.
The facility failed to post oxygen warning signs for two residents requiring oxygen therapy, despite the presence of oxygen tanks and concentrators in their rooms. This oversight was confirmed by staff interviews and contradicted the facility's policy on oxygen administration, which mandates 'No Smoking' signs to prevent safety risks.
The facility failed to ensure that pharmacist medication regimen review recommendations were reviewed by the attending physician for two residents. A pharmacist recommended a gradual dose reduction for a resident's quetiapine fumarate, but the physician did not review it timely. Another resident's Zoloft dose reduction recommendation was ignored by the physician, with the DON acknowledging delays in addressing such recommendations.
A facility failed to accurately document the application of compression stockings for a resident with peripheral vascular disease. Despite documentation indicating the stockings were applied, observations and resident statements confirmed they were not. The resident experienced swollen legs and feet, and the ADON was unsure why the stockings were not reapplied after a shower, highlighting a lapse in documentation and care procedures.
Dietary Manager Lacked Required Qualifications and Meal Substitutions Were Not Properly Managed
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietician, based on observation, interview, and record review. The Dietary Manager did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. During interview, she stated she was not a Certified Dietary Manager and was attending school to become one, having started work at the facility in October 2025 and school in January 2026. The ADM also stated the Dietary Manager did not have to be certified if she was in school. Resident #5 was a [AGE]-year-old female with a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Her nutritional risk assessment reflected a significant weight loss of 9.1% (14.2 pounds) in 1 month, with the RD noting the loss may have been related to hospitalizations in February and that the resident was also at risk for weight fluctuations related to bilateral lower extremity edema and diuretic therapy. The resident’s nutritional interventions included house shakes twice daily and weekly weights for 4 weeks. Her weight summary before 02/03/2026 showed stable weight from November 2025 through January 2026. During observation, the Dietary Manager did not follow food storage directions for a container of whipped topping in the reach-in refrigerator; she stated she had not read the label and was unaware that the product should be frozen to use the listed discard date. During lunch service, Resident #5 received potato soup instead of the chicken and sausage gumbo listed on the tray ticket, and she stated she did not want the potato soup because she had already had potato soup as the soup of the day. The tray ticket showed the meal was to include soup, entree, starch, salad, bread, dessert, condiment, and beverage, and the menu substitution for that day listed ham and cheese sandwich as the meat substitution. The ADM stated the loaded baked potato soup was intended to meet protein requirements, while the RD stated the Dietary Manager should have contacted her before substituting it because it did not provide as much protein as the chicken and sausage gumbo and should have been documented on the substitution log.
Food Preferences and Diet Orders Not Honored
Penalty
Summary
The facility failed to ensure Resident #5 received food that matched her preferences and provided equal nutritive value when her Tuesday lunch tray was altered from the planned chicken and sausage gumbo to loaded potato soup. Resident #5, a female with a BIMS score of 09/15 and recent significant weight loss noted by the RD, told staff she did not want potato soup because she had already had potato soup as the soup of the day. Her tray ticket reflected a preference of no sausage and listed the meal components, including the gumbo entree, but the meal observed on the tray consisted of 2 bowls of potato soup instead of the ordered entree. The record showed the facility’s lunch menu for that meal included chicken and sausage gumbo, and the menu substitution for the meat item was ham and cheese sandwich. The ADM stated the loaded baked potato soup recipe should meet protein requirements because it contained bacon, cheese, milk, and sour cream, but the RD later stated she would not have agreed that loaded potato soup was an adequate substitution for chicken and sausage gumbo and would have added chicken because the soup did not provide as much protein as the original entree. The facility’s diet manual and substitution policy required substitutions of equal value and indicated meat servings should be provided at lunch according to calorie level. The facility also failed to honor Resident #5’s food dislikes on Friday lunch when her tray included fried okra, fried fish, and hushpuppies even though her tray ticket reflected she disliked fried-breaded foods and she reported fried foods affected her digestion after gallbladder removal. LVN I confirmed she was not supposed to have fried foods on her tray but could not explain why they remained on it. In addition, the facility failed to update Resident #16’s tray ticket to reflect her Negotiated Risk Agreement allowing a regular diet instead of the mechanically soft diet shown on her order summary and tray ticket; when she requested a regular tray, nursing staff had to return to the kitchen because the ticket still showed mechanical soft, and the Dietary Manager stated she was allowed a regular diet because she had the right to request it.
Kitchen Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation and interview, the ice machine had black circular spots on the inside above the ice. The DM confirmed the spots were present, stated they did not look like mold, and was able to wipe them off with an unnamed substance on a paper towel. She stated she cleaned the inside of the ice machine once a week by placing a plastic bag on top of the ice and cleaning the inside, and said it was important to keep the ice machine clean because residents could drink whatever contaminants were in the ice machine. In the reach-in refrigerator in the food preparation area, containers of whipped topping were observed with a date of 03/03/2026 and a use-by date of 07/06/2027. The container also stated that when frozen, the use-by date was 06 July 2027. The DM stated she was not aware that the product needed to be frozen for that discard date to apply. In the reach-in freezer, raw protein foods were stored next to fully cooked food products. The DM and [NAME] J stated raw protein foods should not be stored near fully cooked foods because blood leaking from raw protein packages could contaminate the fully cooked food products. There was also a food product observed without a name on its label, and the DM stated food products needed to have the name of the food product so staff would know what it was. In addition, three buckets of food products in the food preparation area were observed without labels. [NAME] J identified the buckets as cornmeal, flour, and sugar, and stated they were not labeled. The DM stated she oversaw the kitchen to ensure everything was in order, and also stated that when she was off work, things became unorganized with food storage.
Infection Control Lapses During Incontinent Care and Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 2 residents reviewed for infection control. For Resident #3, whose record showed diagnoses including dementia, schizophrenia, hyperlipidemia, major depressive disorder, type 2 diabetes mellitus, hypertension, and chronic kidney disease, the quarterly MDS indicated a BIMS score of 15 and that the resident was always incontinent of bladder and frequently incontinent of bowel. The care plan directed staff to provide pericare after each incontinent episode. During observation of incontinent care, CNA C did not sanitize between her fingers when using sanitizer between glove changes while providing care for Resident #3. In interview, CNA C stated she did not sanitize between her fingers, said she was nervous and forgot, and stated she had received infection control training within the year. For Resident #7, whose record showed diagnoses including hyperlipidemia, COPD, major depressive disorder, and neoplasm of uncertain behavior of skin, the quarterly MDS indicated a BIMS score of 15 and that the resident had two pressure ulcers. The care plan identified enhanced barrier precautions due to wounds and directed staff to use gown and gloves during high-contact care activities. During observation of wound care, LVN D did not gown up before entering the room and providing care, despite a sign and protective equipment being present by the door. After cleaning the wound, LVN D changed gloves but did not sanitize her hands before applying the treatment and dressing. In interview, LVN D stated she forgot the resident was on enhanced barrier precautions, said the precautions were new to her, and stated she had dipped her fingers in sanitizer but did not sanitize her whole hands between glove changes.
Privacy and Confidentiality Failures During Care and on an Unlocked Medication Cart
Penalty
Summary
Resident #8, who had diagnoses including end stage renal disease, major depressive disorder, hyperlipidemia, anxiety disorder, and dependence on renal dialysis, was observed receiving perineal care while CNAs A and B attempted to pull the privacy curtain around the bed. The curtain was too short in width to go around the bed completely, and Resident #8 could be seen by the roommate and could have been seen by someone opening the room door. Record review showed the resident had a BIMS score of 5, indicating severe cognitive impairment, and was incontinent of bladder and frequently incontinent of bowel. The care plan directed staff to provide pericare after each incontinent episode. The facility also failed to protect resident information when a computer screen on a medication cart located outside the dining room and in the entrance hallway was left unlocked and unsupervised with confidential resident information visible. A COTA confirmed the screen was unlocked and displayed confidential information, and the MDS nurse stated she had left it unlocked accidentally and that it needed to be locked for HIPAA reasons. The ADM stated the laptop on the medication cart needed to be locked and noted the MDS nurse did not typically work on the floor and may have forgotten.
MDS Assessment Omitted Colon Cancer Diagnosis
Penalty
Summary
The facility failed to ensure Resident #3’s quarterly MDS assessment accurately reflected his status by omitting his diagnosis of colon cancer. Record review showed the resident was initially admitted and later re-admitted with diagnoses including GI bleeding, and hospital documentation reflected invasive colonic adenocarcinoma. However, the quarterly MDS dated 12/08/2025 listed a BIMS score of 15 out of 15 and did not include colon cancer as a diagnosis, and the care plan also did not mention colon cancer. During interviews, the resident stated he went to chemotherapy because he had colon cancer. The MDS Nurse and Reimbursement Consultant stated the resident returned to the facility with stage 4 colon cancer and was currently receiving chemotherapy for palliative purposes. They explained that diagnoses were reviewed from pertinent medical records and added to the MDS assessments and face sheets, and confirmed colon cancer was not reflected on the MDS. The DON and ADM also verified the diagnosis was missing from the MDS assessment, stating it needed to be included because the resident had colon cancer and staff needed to be aware of it.
Care Plans Not Updated for Cancer Treatment and Negotiated Diet Risk
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents with identified needs. For one resident, the record showed a re-admission with diagnoses including dementia and GI hemorrhage, and hospital documentation reflected invasive colonic adenocarcinoma. The resident’s quarterly MDS did not reflect colon cancer as a diagnosis, and the care plan did not mention the cancer or that the resident was going to chemotherapy after re-admission. During interviews, the resident stated he went to chemotherapy because he had colon cancer, and facility staff acknowledged the diagnosis should have been reflected in the care plan so nursing staff would be aware of it and any related treatment needs. For another resident, the admission record reflected dysphagia and the MDS showed a mechanically altered diet. The resident also had a Negotiated Risk Agreement stating she preferred to eat regular foods even though she was at risk for aspiration. However, the care plan did not address the Negotiated Risk Agreement and did not state that she was allowed to eat a regular diet instead of the prescribed mechanical soft diet. The order summary still reflected a mechanical soft diet, and the care plan only noted that the resident had a diet order other than regular and was at risk for unplanned weight loss or gain. During observation and interview, the resident received a mechanically soft lunch tray, then requested a regular diet meal. Nursing staff had to check with the kitchen, which said it was okay to give her a regular diet tray, while staff at the time were not aware that the tray ticket still reflected mechanical soft. Facility staff acknowledged the resident had a Negotiated Risk Agreement because she chose to eat regular foods, and the MDS nurse stated that this should have been in the care plan so staff would know it was okay for her to have a regular diet because it was her preference and her right.
Incomplete Perineal Care During Incontinent Care
Penalty
Summary
Incontinent care was not provided in accordance with appropriate treatment and service practices for Resident #3. During observation on 03/19/2026 at 12:35 p.m., CNA C provided incontinent care but did not clean the resident’s lower abdomen area or the left and right groin areas. During interview later that day, CNA C stated she did not clean those areas because she was nervous and forgot, and she reported receiving incontinent care training within the year. Resident #3’s record showed an admission date of 08/18/2023 and a readmission date of 12/04/2025, with diagnoses including dementia, schizophrenia, hyperlipidemia, major depressive disorder, type 2 diabetes mellitus, hypertension, and chronic kidney disease. The quarterly MDS indicated a BIMS score of 15, showing the resident was cognitively intact, and that the resident was always incontinent of bladder and frequently incontinent of bowel. The care plan directed staff to provide pericare after each incontinent episode. The DON stated staff should clean residents’ lower abdomen area and the left and right groin areas during incontinent care to ensure proper cleaning and prevent infection, and the facility policy on perineal care directed wiping across the pubis area and continuing care to the scrotum and inner thigh.
Unsigned Physician Orders and Delayed Review of RD and Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure physician, physician assistant, nurse practitioner, or clinical nurse specialist orders were in place for the immediate care and needs of 2 residents reviewed for physician services. For Resident #5, the quarterly MDS dated 02/27/2026 reflected a BIMS score of 09 out of 15, indicating moderate cognitive impairment. The RD’s Nutritional Risk Assessment, also dated 02/27/2026, documented a significant weight loss of 9.1% (14.2 pounds) in 1 month, with possible contributing factors including recent hospitalizations, fluid fluctuations related to BLE edema, and diuretic therapy. The RD recommended house shakes BID and weekly weights for 4 weeks, but the communication between the dietitian and attending physician showed Dr. K had not signed the diet recommendations. For Resident #3, the record reflected diagnoses including dementia and Type 2 diabetes, and the quarterly MDS dated 12/08/2025 showed a BIMS score of 15 out of 15. The pharmacist’s Medication Regimen Review dated 02/25/2026 recommended increasing Januvia to 100 mg and attempting to discontinue sliding scale insulin to reduce needle sticks and medication burden. Dr. K signed the medication regimen review on 03/09/2026, but the facility had not updated the resident’s orders by 03/19/2026, and Januvia remained ordered at 50 mg daily. During interview, the DON and Compliance Nurse stated pharmacy and RD recommendations were emailed to the DON or MDS Nurse to send to the doctor for signature, and the signed orders were then returned for entry into the medical record. They stated there had been many unsigned orders and that Resident #3’s orders were not updated because Dr. K had been called for clarification on his note and had not responded. The Compliance Nurse stated responses should take less than 3 days, and the MDS Nurse and RD both described ongoing problems with physician response times and getting recommendations signed. The facility policies reflected that physician orders must be signed and dated, that the physician must supervise each resident’s medical care, and that nutrition and drug regimen recommendations should be signed and returned by the physician.
Unlocked Medication Cart in Hallway
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 3 medication carts reviewed, specifically medication cart #1. During observation and interview on 03/17/2026 at 11:46 AM, medication cart #1, located right outside the dining room in the facility's entrance hallway, was found unlocked with the button used to open the cart popped out. No residents or visitors were present at the time. COTA F walked by the cart and then got MDS Nurse E, who confirmed the cart was unlocked and stated that the narcotics inside medication cart #1 were kept in another container that was locked inside the cart. MDS Nurse E said it was important for medication carts to be locked so no medication could be taken out by someone who did not know what they were doing. During interview on 03/17/2026 at 4 PM, the ADM stated medication carts should be locked when left unattended and said MDS Nurse E did not typically work on the floor so she may have forgotten. Record review of the facility's policy, Medication Storage in the Facility, dated 03/2025, stated medications and biologicals are stored safely, securely, and properly.
Medical Record Missing Colon Cancer Diagnosis
Penalty
Summary
The facility failed to maintain Resident #3’s medical records in a complete and accurately documented manner when his diagnosis of colon cancer was not included on his admission record, quarterly MDS assessment, or care plan. Resident #3’s admission record listed diagnoses including dementia and gastrointestinal hemorrhage, but did not reflect colon cancer, even though hospital documentation showed he had invasive colonic adenocarcinoma. His quarterly MDS assessment dated 12/08/2025 showed a BIMS score of 15 out of 15 and also did not include colon cancer, and the undated care plan made no mention of colon cancer or chemotherapy. During interview, Resident #3 stated he had gone to chemotherapy because he had colon cancer. The MDS Nurse E and the Reimbursement Consultant stated Resident #3 returned to the facility with stage 4 colon cancer and that the diagnosis should have been added to the face sheet so it could carry over to the MDS assessment and care plan. The DON and ADM also stated the face sheet should have included colon cancer because he was going to chemotherapy. CNAs A, G, and H stated they knew Resident #3 had cancer and that he returned from chemotherapy weaker and needing more assistance on those days.
Multiple Food Service Sanitation and Equipment Deficiencies Identified
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations of unsanitary and poorly maintained kitchen equipment and areas. The ice machine in the kitchen was found to be leaking, with water pooling on the floor and wet towels surrounding the machine. The double door standing refrigerator was leaking water from the top mechanism, resulting in containers of food sitting in standing water at the bottom of the unit. Both the silver refrigerator and the white deep freezer had accumulations of ice inside the walls, and their lids, bases, and inside seals were visibly soiled with a black substance. Despite these issues, the temperatures of the refrigeration units were within the appropriate range. Further observations revealed that the kitchen floors were stained and soiled with food particles, two electrical outlets were visibly soiled, the kitchen drying racks were rusty, and the large return filter was covered with dust. The vent hood over the stove was inoperable, with its switch covered by blue tape and marked as not to be touched. Interviews with dietary staff confirmed that the ice machine had a recurring water leak due to a clogged drain, and the double door refrigerator had been leaking for an extended period. Staff also acknowledged the presence of accumulated ice and soiling in the refrigeration units, and that these issues had been reported to the Maintenance Director and Dietary Manager but remained unresolved. The Maintenance Director confirmed the ongoing issues with the kitchen equipment, including the need for a replacement part for the vent hood, a recurring clog in the ice machine drain, and a broken door gasket on the double door refrigerator. The Director of Nursing, who was new to the facility, confirmed the unsanitary conditions and stated she was previously unaware of these issues. The facility's policy and the FDA Food Code require food to be stored in clean, dry locations and equipment to be clean to sight and touch, which was not met in these instances.
Dining Room Air Conditioning Vents Found Soiled and Rusty
Penalty
Summary
Surveyors observed that the facility's dining room had eight ceiling air conditioning vents, all of which were visibly soiled with a black substance and rust. The return vent in the dining room was also covered with dust. The Maintenance Director confirmed these findings, stating that the Housekeeping Department was responsible for cleaning the return vent, while she was responsible for the ceiling vents. She reported that she occasionally wiped the vents and sprayed bleach on the black substance, but this was ineffective in removing it. She also noted that the vents were rusty and needed to be painted or replaced. There was no set schedule for cleaning the vents, and the last documented cleaning occurred in October or November of the previous year. The Maintenance Director acknowledged that the return vent cleaning was overdue. The DON also confirmed the vents were soiled and rusty, and the return vent was dusty, emphasizing the importance of clean vents for residents' access to unsoiled air. Review of the facility's policy indicated that preventive maintenance should be completed routinely and according to protocol, but this was not followed in this instance.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, over a period of 42 days between May 11, 2024, and August 12, 2024. This deficiency was identified through interviews and record reviews, including the CMS PBJ staffing data report and facility timesheets. The absence of RN coverage on specific dates was confirmed, indicating a lack of compliance with the required staffing regulations. Interviews with the current Director of Nursing (DON) and the previous administrator revealed that the facility faced challenges in maintaining RN coverage due to staffing shortages and competition for nursing staff. The current DON, who started on July 17, 2024, stated that her hours were not recorded on a timesheet as she is salaried. The previous administrator mentioned efforts to fill shifts with interim staff and regional nurses, but acknowledged the difficulty in securing a permanent DON or RN to meet the staffing requirements.
Deficiencies in DNR Documentation for Residents
Penalty
Summary
The facility failed to ensure that residents had the right to formulate an advance directive and determine their choice regarding CPR, as evidenced by deficiencies in the documentation of Out of Hospital (OOH) Do Not Resuscitate (DNR) orders for three residents. Resident #5's OOH DNR was missing the physician's printed name, which is a necessary component for the document's validity. This oversight occurred despite the resident's documented DNR status and the presence of a care plan that included DNR interventions. Resident #25's OOH DNR was incomplete as it lacked a second signature from the resident's representative at the bottom of the document, where all signatories are required to sign again. This resident had severe cognitive impairment, and the responsibility for ensuring the DNR's completeness fell to the representative. The facility's failure to ensure the document was fully executed could lead to confusion regarding the resident's end-of-life wishes. Similarly, Resident #40's OOH DNR was missing the resident's second signature at the bottom of the document. Despite being cognitively intact and having a care plan that included DNR interventions, the resident's DNR documentation was not properly completed. During an interview, facility staff acknowledged the oversight and the potential issues it could cause with external agencies not honoring the DNR due to incomplete documentation.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by several deficiencies observed in the handling and administration of medications. The survey revealed that glucometer logs were not maintained properly, with missing entries for specific dates, and there was no clear identification of which glucometer was being tested. This lack of documentation and identification could lead to inaccuracies in blood glucose monitoring, as staff were not verifying if nightly controls were being conducted. Additionally, the facility did not ensure the removal of expired supplies, as observed with a box of IV alcohol caps that had passed its expiration date. Furthermore, loose pills were found stored in a medication cart, which is against the facility's policy due to the risk of contamination and medication errors. The Director of Nursing (DON) acknowledged that staff should not store pills ahead of time and emphasized the importance of following the Medication Administration Procedures. The report also highlighted a specific incident involving a resident with a history of gastrointestinal issues and other medical conditions. The resident did not receive the prescribed dose of omeprazole, and the administration of polyethylene glycol was inaccurately documented. The Licensed Vocational Nurse (LVN) involved failed to administer the correct medications initially and did not document the resident's refusal of the full dose of polyethylene glycol accurately. This oversight could potentially affect the resident's treatment for chronic gastrointestinal problems.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for three residents who required them. Resident #25, a female with Alzheimer's disease and a draining wound on her left leg, did not have EBP implemented until after the wound was observed to be draining. Similarly, Resident #26, who had a central port for dialysis, reported that staff never wore gowns during her care, and there was no order for EBP in her records. Resident #43, who had an indwelling catheter, also did not have EBP in place until after it was noted by the Director of Nursing (DON) that it should have been implemented. Additionally, the facility failed to ensure proper storage of clean items, as observed with a name tag being stored in a box of clean disposable wooden spoons on a medication cart. This incident was acknowledged by the Licensed Vocational Nurse (LVN) and the DON, who recognized the contamination risk and removed the box from the cart. The facility's policy on Enhanced Barrier Precautions and infection control measures was not adequately followed, leading to these deficiencies. The DON admitted to being unaware of the need for EBP for the residents in question until after the surveyor's observations. The facility's failure to implement EBP for residents with open wounds, central ports, and indwelling catheters, as well as the improper storage of clean items, posed a risk for the spread of infection and cross-contamination among residents.
Failure to Implement Comprehensive Care Plan for Resident with Chronic Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a chronic wound, which did not include measurable objectives and time frames to meet the resident's medical and nursing needs. The care plan did not reflect that the resident was on enhanced barrier precautions (EBP), which are necessary to prevent infections for residents with open wounds. This oversight was identified during a review of the resident's records and observations, where it was noted that the care plan lacked mention of EBP despite the resident having a chronic wound. The resident, who was admitted with Alzheimer's disease, chronic kidney disease stage 3, and seizures, had a significant change in condition with a skin tear and a full-thickness wound on her left lower leg. Despite the presence of a wound care order, there was no corresponding order for EBP, and staff were observed not using personal protective equipment (PPE) when interacting with the resident. The Director of Nursing (DON) was unaware of the resident's open draining wound until it was brought to attention, indicating a lapse in communication and care planning. This deficiency could place residents at risk of not receiving necessary care or services tailored to their specific needs.
Failure to Apply Compression Socks as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not follow provider orders and care plan interventions by failing to apply knee-high compression socks on a resident with edema. The resident, who had a history of non-ST elevation myocardial infarction, hypertensive heart disease, peripheral vascular disease, and chronic atrial fibrillation, was observed with swollen legs and feet and reported that staff had not applied her compression socks as requested. Observations and interviews revealed that the resident was wearing non-skid socks instead of the prescribed compression stockings. Despite the order for compression socks to be applied daily, the resident was found without them on multiple occasions. LVN A acknowledged the oversight and was observed searching for the compression socks, eventually finding them in a locked cart in the medication storage room. The ADON confirmed that the socks should have been worn during the day and removed at bedtime, and acknowledged that the resident would experience swelling without them.
Failure to Prevent Hazardous Materials in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment for Resident #5 by allowing potentially hazardous materials in her room. Resident #5, a female with moderate cognitive impairment and a history of heart conditions, was found with a jar of medicated chest rub and a bottle of hairspray on her nightstand. The resident did not have an order to self-administer medications, and the presence of these items posed a risk due to her cognitive impairment. The Director of Nursing (DON) acknowledged that the resident should not have had these items, as they could be used incorrectly and cause harm. Resident #40, a male with intact cognition and a history of peripheral vascular disease and major depressive disorder, was found with an open beer can in his room. Although his care plan allowed for alcohol consumption at social functions, staff were unaware of the beer in his room. The resident claimed that staff knew about the beer, but interviews with staff members revealed they had never seen him with alcohol. The DON expressed concern about potential interactions between the beer and the resident's medications. The facility's policy prohibited medications and aerosol cans in resident rooms unless specifically ordered by a doctor. The DON admitted that the facility had overlooked assigning a new champion to monitor Resident #40 after the previous one left. Additionally, the facility had issues with visitors entering through side doors, which could have contributed to the presence of unauthorized items in resident rooms.
Failure to Post Oxygen Warning Signs for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents who required oxygen therapy, as evidenced by the absence of oxygen warning signs on their doors. Resident #25, a female with Alzheimer's disease, chronic kidney disease, and seizures, was observed with an oxygen concentrator and portable oxygen tank in her room without any signage indicating the presence of oxygen. Her care plan included the provision of oxygen as needed for dyspnea or low oxygen saturation, yet the necessary precautions were not in place. Similarly, Resident #34, a male with atrial fibrillation, sleep apnea, and influenza, was seen using oxygen therapy without any signs on his door to alert others of the oxygen use. His care plan also included oxygen therapy as ordered by the physician. Interviews with facility staff, including an LVN, the ADON, and the DON, confirmed that oxygen signs were required but not posted for residents using oxygen. The facility's policy on oxygen administration emphasized the importance of placing 'No Smoking' signs in areas where oxygen is administered and stored, to prevent the use of flames or sparks nearby. The lack of signage could lead to increased respiratory complications and unawareness of oxygen use, posing a safety risk to residents and staff.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the pharmacist's medication regimen review recommendations were reviewed by the attending physician for two residents. For Resident #4, the pharmacist recommended a gradual dose reduction of quetiapine fumarate, but the physician did not review this recommendation in a timely manner. The Director of Nursing (DON) was unsure if the provider had reviewed the recommendation, and it was later found that the provider had sent a form indicating the resident should continue with the same dose, but this form was not dated. For Resident #16, the pharmacist recommended a gradual dose reduction for Zoloft, but the physician had not addressed this recommendation as of the survey date. The DON revealed that the facility's medical records clerk delivered the pharmacy recommendations to the physician's office, but the physicians often ignored these recommendations. The DON acknowledged that the recommendation for Resident #16 had not been addressed, and it was only on the survey date that a signed form from the physician was provided, stating that the risk of clinical deterioration outweighed the benefit of the recommended change.
Failure to Accurately Document Compression Stocking Application
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the application of compression stockings. The resident, a female with a history of non-ST elevation myocardial infarction, hypertensive heart disease, peripheral vascular disease, and chronic atrial fibrillation, was supposed to have knee-high compression stockings applied as part of her care plan to manage her peripheral vascular disease. However, the nursing staff documented that the compression stockings were applied on specific days, despite the resident stating that they were not put on, and observations confirming that she was wearing regular ankle socks instead. The discrepancy was noted during observations and interviews, where the resident expressed that her legs and feet were swollen and that she had requested the compression stockings, but they were not applied. The facility's policy on documentation requires accurate and complete recording of care provided, which was not adhered to in this case. The Assistant Director of Nursing (ADON) was unsure why the compression stockings were not reapplied after the resident's shower, indicating a lapse in following the prescribed care plan and documentation procedures.
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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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