Skyline Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 3326 Burgoyne, Dallas, Texas 75233
- CMS Provider Number
- 455653
- Inspections on file
- 46
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Skyline Nursing Center during CMS and state inspections, most recent first.
Staff failed to protect resident dignity and privacy when a resident’s mattress was placed on the floor after a fall without a physician order or care plan direction, and when staff loudly discussed resident needs and incontinence in the dining room and hallway where others could hear. The incidents involved residents with dementia, severe cognitive impairment, schizophrenia, bipolar disorder, and other neurocognitive disorders, and included public comments about toileting, eating refusal, changing a resident, and a resident removing his pants.
Soiled, stained, worn, and missing linens were found on several resident beds, including cracked or torn pillows and beds without pillowcases or a blanket. Staff reported ongoing linen shortages on the unit, use of sheets to dry residents when towels were unavailable, and beds sometimes being left stripped until clean linen arrived. Housekeeping and admin staff also described poor linen inventory control and discarded items not being documented, contributing to insufficient clean linen and damaged items remaining in use.
Failure to Provide Timely ADL Assistance and Grooming Care: A resident was found with a soiled brief after stating incontinence care had not been provided that day, while other residents dependent on staff for personal hygiene were observed with dirty or untrimmed fingernails and an unclean face with eye buildup. Records and staff interviews showed the residents had diagnoses including dementia, hemiplegia, CVA, MS, and impaired mobility, and staff stated CNAs and nurses were responsible for routine hygiene, grooming, and incontinence care.
Late Lunch Meal Service: Meal postings showed lunch at noon, but observations found that hall trays for one hall were repeatedly served late, with the last trays not reaching residents until well after the posted time. A resident and two other residents stated breakfast and lunch trays were often late and that their hall was usually served last; staff, including a CNA, LVN, and the Dietary Manager, confirmed that hall trays could be delayed until 12:45 PM to 1:30 PM and that the hall in question was typically last.
Infection control failures were observed during incontinent care and meal assistance for multiple residents. A CNA changed gloves without hand hygiene during peri-care, another CNA used bare hands to handle and cut resident food and handed food directly to a resident, and a CNA provided incontinent care for a resident on EBP without a gown and changed gloves without hand hygiene. The DON stated staff were expected to use proper PPE, utensils or gloves for food handling, and hand hygiene between glove changes.
Failure to Notify Responsible Party of Fall and New Wound: A resident with dementia, schizophrenia, and high fall risk had a fall with a skin tear above the eye and later had a new sacral pressure wound identified. Records and staff interviews showed the family member/medical POA was not notified of the fall or the new wound, while the federal fiduciary listed in the chart handled only VA finances and was not the resident’s medical decision-maker.
Failure to provide privacy during incontinent care: A CNA closed the door but did not pull the privacy curtain around a resident's bed while giving incontinent care, leaving the roommate with full view of the care. The resident had severe cognitive impairment, was always incontinent, and required substantial assistance with ADLs. The CNA acknowledged forgetting to pull the curtain, and the DON stated staff were expected to close the door and pull curtains during resident care.
Failure to arrange routine dental services for a resident with severe cognitive impairment, dysphagia, and dependence for oral hygiene. The resident had missing and broken teeth, and the chart contained no completed dental care or dental assessments. Social work staff stated they were responsible for scheduling dental appointments but could not locate any dental records for the resident.
A resident with dementia and moderate cognitive impairment, who required supervision or partial/moderate assistance with ADLs, requested help with his bank account in the dining room. The Activity Director, despite knowing only certain staff were authorized to assist with resident finances, allowed a housekeeper to help the resident set up an electronic transfer on his cell phone. Later, a $300 electronic transfer from the resident’s bank account was found to have been sent to a phone number matching the housekeeper’s number, which the resident did not recognize, and a screenshot from the resident’s phone confirmed the transfer.
A CNA failed to perform hand hygiene before donning gloves, between glove changes, and after providing incontinence care to a resident with severe cognitive impairment and multiple medical conditions. The CNA continued to assist the resident and his roommate without following required infection control procedures, contrary to facility policy and training.
Two residents with cognitive impairment were involved in a physical altercation resulting in injury, but the incident was not reported to the state agency as required by facility policy. The DON and Administrator determined not to self-report the event, citing the residents' low BIMS scores and memory care status.
The facility failed to maintain food safety and hygiene standards, with bruised tomatoes found in storage, improper hand hygiene, and inadequate hair restraints among dietary staff. Additionally, food temperatures were not checked before serving, posing a risk of contamination and food-borne illness.
The facility failed to ensure a clean and sanitary environment, with unsanitary conditions in shower rooms and delayed linen changes for a resident with severe cognitive impairment and a productive cough. Housekeeping staff used an ineffective odor control solution instead of a sanitizing solution, and the facility's policies did not adequately address cleaning procedures, posing a risk to resident health and safety.
A resident with moderate cognitive impairment and physical limitations was unable to reach or use the call light due to its improper placement and his involuntary hand movements. Despite the facility's policy requiring call lights to be within reach, observations revealed the resident's call light was not accessible, placing him at risk of not being able to contact caregivers.
The facility failed to ensure proper nail care and hygiene for two residents with severe cognitive impairments. One resident, on hospice care, had long and chipped nails, while another diabetic resident had long, discolored, and dirty nails. Staff acknowledged the oversight and the potential risks for infection and injury, highlighting a lapse in adherence to the facility's grooming care policy.
The facility failed to provide adequate pharmaceutical services, as evidenced by unsecure medications on Nurses Cart Hall 100. RN C did not remove medications from broken blister packs and failed to check an expired insulin pen, risking drug diversion and diminished medication effectiveness. The DON confirmed that medications with broken seals should be discarded and insulin pens need to be dated and discarded after their shelf life.
A facility failed to maintain an effective infection control program when a CNA did not change gloves or perform hand hygiene during incontinence care for a resident. Despite initial handwashing and glove use, the CNA handled clean items after touching soiled materials without changing gloves, contrary to facility policy. This breach was acknowledged by the DON, who noted the increased infection risk due to non-compliance with established protocols.
A resident with cognitive impairments was financially exploited by a facility employee who used the resident's debit card for unauthorized transactions, resulting in a loss of approximately $25,000. The employee, an Activities Assistant, was trusted with the card to make purchases for the resident but instead made personal withdrawals and purchases. The facility lacked adequate oversight and systems to prevent such misappropriation, leading to a significant deficiency in protecting resident property.
Dignity and Privacy Failures
Penalty
Summary
The facility failed to ensure residents had a dignified existence, self-determination, communication, and privacy for 4 of 6 residents reviewed. The report identified that Resident #178’s care plan was not followed when his mattress was placed directly on the floor in his room after a fall, even though the mattress placement was not included in the care plan and there was no physician order or direction from the ADON or DON for that action. Resident #178 was observed lying on the mattress on the floor in a room that was visible from the hallway, and he was wearing only an incontinent brief at the time. The report also documented multiple instances of staff discussing resident information loudly in areas where other residents could hear. CNA Q loudly told Resident #21 that it was embarrassing that he had urinated in his pants in the dining room while his clothing was soiled and wet. CNA K loudly stated across the dining room that Resident #178 did not want to eat anymore and discarded his protein shake. CNA Q also loudly announced in the dining room that she was going to change Resident #184. In another observation, ADON M loudly told CNA K that Resident #14 had taken his pants off and was walking down the hall, and CNA K repeated the information to another CNA in front of residents. The residents involved had significant cognitive and neurological diagnoses, including dementia, schizophrenia, bipolar disorder, frontotemporal neurocognitive disorder, and severe cognitive impairment based on BIMS scores. The facility’s resident rights policy stated that residents have a right to dignity, self-determination, and privacy in oral, written, and electronic communications.
Soiled and Worn Linens Found on Resident Beds
Penalty
Summary
The facility failed to ensure residents had clean, in-good-repair linens and enough linen available on the downstairs secured unit. During observation, four resident beds were found with soiled, stained, worn, or missing linen. One resident bed had soiled and worn linen, another had soiled linen, and two additional beds had soiled, stained, and worn linens. Two pillows were observed cracked, torn, or without pillowcases, and one bed had no blanket. The charge nurse stated that linens should be changed when soiled and that fresh linens are placed on beds during baths, which occur every other day. Staff interviews described ongoing linen shortages and inconsistent replacement of damaged items. The charge nurse reported she had to go to laundry about once per week because there was not enough linen on the unit and said she had reported the shortage to the ADON several times. A CNA reported that staff sometimes did not have enough towels after baths and would use sheets to dry residents. Another CNA stated that when clean linen was not available, beds were stripped and left until linen arrived, and that some pillows on the unit had cracks. Staff also described the linens as dingy, old, hard in texture, and insufficient in quantity. Housekeeping and administrative staff confirmed problems with inventory and replacement practices. The Housekeeping Manager said the facility was expected to maintain three times the amount of linen per resident, but he had not completed a linen inventory since starting and the inventory log was not available for review. The Housekeeping Lead stated linen was being discarded without documentation, contributing to the shortage, and that she had observed the condition of pillows and linens on the unit. The Administrator stated his expectation was that staff replace torn or tattered linen, and the facility laundry services policy required linen to be kept clean, in good repair, and in sufficient quantities for every licensed bed.
Failure to Provide Timely ADL Assistance and Grooming Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary assistance with grooming, hygiene, and incontinence care. The report identified four residents reviewed for ADL care who did not receive the expected care: one resident was found with a soiled brief after stating he had not been changed that day, two residents were observed with unclean or untrimmed fingernails, and one resident was observed with an unclean face and buildup in the eye area. Resident #169 had diagnoses including dementia, muscle wasting and atrophy, hypertension, abnormalities of gait and mobility, anemia, and disseminated intravascular coagulation. His MDS reflected a BIMS score of 13 and dependence on staff for toileting. His care plan stated he required dependent staff participation with toileting hygiene and had bowel and bladder incontinence related to impaired mobility. During observation, he was seen with a soiled brief and stated he had not been changed that day and that changing had not been offered by staff. CNA interviews stated incontinence care was provided every 2 hours or every 2 to 3 hours during rounds and as needed, and the DON stated CNAs and nurses were responsible for checking residents and providing incontinent care. Resident #10 had diagnoses including hypertension, non-Alzheimer's dementia, and hemiplegia or hemiparesis. His MDS showed a BIMS score of 7/15 and substantial to maximal assistance needed with personal hygiene. His care plan stated he required sub/max assistance with personal hygiene. During observation, his fingernails on both hands were approximately 0.4 cm long and dirty, and he stated he wanted them cleaned and trimmed. A CNA observed the nails and stated they looked long, dirty, and needed to be cleaned and trimmed. Resident #15 had diagnoses including CVA, non-Alzheimer's dementia, extrapyramidal and movement disorder, and bipolar disorder, with a BIMS score of 12/15 and dependence with personal hygiene. He was observed lying in bed with an oily face and buildup from his eyes in the inner corner by the nose, and he stated his face was not cleaned that day. Resident #50 had multiple sclerosis and dementia, was dependent on staff for personal hygiene, and was observed with long fingernails that were discolored with dark brown residue under the nails and nail beds. The facility policy stated residents are to be provided necessary care and services to maintain well-being, and the grooming policy stated fingernail care is given to clean and keep nails trimmed.
Late Lunch Meal Service
Penalty
Summary
The facility failed to ensure that lunch meals were served at the posted scheduled time on 04/12/26 and 04/13/26. The meal postings in the main dining room showed lunch at 12:00 PM, but observations showed that residents on 200 hall had not yet received lunch trays at 12:45 PM on 04/12/26, and the last lunch hall tray was not passed until 1:36 PM. On 04/13/26, the last hall tray for 200 hall was still being passed at 12:54 PM. The Dietary Manager stated that dining room trays for lunch start at noon, but hall trays can take from 12:45 PM to 1:30 PM before all residents receive lunch, and that 200 hall was usually the last hall served. Resident #174, who had a BIMS of 14 and was cognitively intact, stated at 12:45 PM on 04/12/26 that lunch trays were late and 200 hall was served last. Residents #37 and #38, both cognitively intact or moderately cognitively impaired based on MDS assessments, stated at 1:38 PM on 04/12/26 that breakfast and lunch trays were late most times and that their hall was last served each day; both preferred to eat in their room. A CNA stated on 04/13/26 that 200 hall lunch trays were last and that it could take from 12:30 PM to 1:00 PM before residents received their meal trays. An LVN stated on 04/14/26 that lunch meal times were posted at noon but hall trays could take up to 1:30 PM to be served, and the Dietary Manager stated the facility did not designate between dining room and hall tray times.
Infection Control Failures During Incontinent Care and Meal Assistance
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for five residents during observed care and meal assistance. The deficiency involved improper glove use, lack of hand hygiene between dirty and clean tasks, bare-hand contact with resident food, and failure to use required PPE during incontinent care for a resident on Enhanced Barrier Precautions. For Resident #164, who had dementia, muscle weakness, and a severely impaired BIMS score, CNA B provided incontinent care while wearing gloves but did not change gloves and perform hand hygiene when moving from soiled care to clean care. During the observation, CNA B also dropped a clean brief on the floor, picked it up, and placed it back on the resident bed. She then continued care with the same gloves, applied skin barrier cream, and later removed the gloves and washed her hands. CNA B stated she should change gloves and perform hand hygiene when going from dirty to clean and should not have picked up the brief from the floor. During lunch observations, CNA K assisted Resident #184, who had frontotemporal neurocognitive disorder and dementia, and Resident #21, who had hemiplegia and hemiparesis following cerebral infarction. CNA K used her bare thumb and pointer finger to hold down each resident's pork chop while cutting it with the resident's fork, then later assisted Resident #184 with feeding while her fingers had visible gravy and meat particles on them. CNA K also picked up a chicken finger with her bare hands and handed it to Resident #157, who had dysphagia, dementia, and delirium. The Administrator and DON stated staff should use utensils or gloves when cutting resident food and should not use bare hands. For Resident #105, who had dementia, hemiplegia or hemiparesis, was always incontinent, and was on Enhanced Barrier Precautions for a wound, CNA N entered the room without PPE, despite signage and PPE being available at the door. CNA N donned gloves and performed incontinent care without a gown, changed gloves without hand hygiene, and completed care before washing her hands at the end. CNA N stated she forgot to wear the gown and acknowledged she should have completed hand hygiene each time she changed gloves. The DON stated staff were expected to gown and glove for high-contact care on Enhanced Barrier Precautions and to perform hand hygiene any time gloves were changed.
Failure to Notify Responsible Party of Fall and New Wound
Penalty
Summary
The facility failed to notify the resident’s responsible party of changes in condition for one resident who had a fall and a newly acquired pressure wound. The resident was admitted with diagnoses including paranoid schizophrenia, senile degeneration of the brain, schizoaffective disorder, and dementia, and his MDS showed a BIMS score of 09, indicating moderate cognitive impairment. His care plan identified impaired cognitive function and high fall risk, with interventions to monitor and report changes in cognition and condition. On 04/12/2026, the resident was found on the floor with blood above his right eye and a skin tear above the eye. The nursing note stated that the resident said he fell off his bed while trying to turn over. The record documented that the physician, DON, federal fiduciary, and hospice were notified. During interviews, the resident’s family member stated she was not called about the fall, and the federal fiduciary stated she was not the person responsible for the resident’s medical care and had not been contacted about the fall. The record also showed a new wound on the sacrum identified on 04/06/2026 as a Kennedy terminal ulcer. Treatment notes documented ongoing wound care for the resident’s left lateral foot diabetic ulcer, and staff interviews indicated uncertainty about who had been notified regarding the new buttocks wound. The family member stated she was not aware of any additional wounds other than the foot wound until she was told by the treatment nurse. Interviews with the BOM, DON, ADON, treatment nurse, and administrator confirmed that the family member was the resident’s medical and financial POA and should have been contacted for changes in condition, while the federal fiduciary handled only VA benefits and finances.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident had the right to personal privacy during incontinent care. Resident #105 was an [AGE] year-old male with diagnoses including hypertension, type 2 diabetes mellitus, cerebrovascular accident, non-Alzheimer's dementia, and hemiplegia or hemiparesis. His annual MDS assessment reflected a BIMS score of 05/15, indicating severely impaired cognition, and he was always incontinent of bowel and bladder. His care plan noted that he required sub/max assistance with ADLs, including oral and personal hygiene. During observation on 04/13/26 at 09:10 AM, CNA N provided incontinent care to Resident #105 after closing the door but without pulling the privacy curtain around the bed. The resident was in the first bed in a room with a roommate present. The roommate was up in a wheelchair, watching TV and moving back and forth to the closet beside the room entrance, and had full view of the care being provided. In interview, CNA N confirmed the curtain was not pulled all the way around the bed and stated it should have been pulled for privacy and dignity, adding that she forgot to do so. The DON later stated staff were expected to close the door and pull curtains when providing resident care and identified the failure to pull the curtain during incontinent care as a violation of the resident's rights to privacy and dignity.
Failure to Arrange Routine Dental Services
Penalty
Summary
The facility failed to assist Resident #117 in obtaining routine dental care after admission. Resident #117 was a [AGE]-year-old male admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, cognitive communication deficit, and vascular dementia. His quarterly MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and he required substantial to maximal assistance with oral and personal hygiene. During observation, he was noted to have missing and broken teeth, and his record did not show any completed dental care or dental assessments. Record review and staff interviews showed the facility could not locate any dental assessments for Resident #117. The social workers stated they were responsible for scheduling dental appointments and were unaware that he had not seen a dentist. The facility policy stated that Social Services coordinates referrals to outside agencies for services not offered by the facility, including dental services, but no completed dental services or assessments were found for this resident.
Failure to Protect Resident From Misappropriation of Funds by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property by an employee. A male resident with dementia and moderate cognitive impairment, as evidenced by a BIMS score of 12, required supervision or partial/moderate assistance with ADLs and had a care plan for impaired cognitive function related to dementia and memory deficit. The facility’s Abuse Prevention and Prohibition Program policy stated that each resident has the right to be free from misappropriation of property and that the facility has zero tolerance for such conduct. According to interviews and record review, the resident requested assistance with his bank account while in the dining room. The Activity Director reported that the resident asked a housekeeper for help with his bank account, and the Activity Director told the housekeeper she could assist him, despite being aware that only the Activity Director and Activity Assistants were authorized to assist residents with financial matters. The Administrator later confirmed that only the Business Office, Activities employees, and Social Workers were authorized to assist residents with financial matters and that these responsibilities could not be delegated to other employees. Subsequently, an electronic transfer of $300 was made from the resident’s bank account to a cell phone number that matched the housekeeper’s number. The Social Worker learned from the resident that an employee had assisted him with sending money to a family member, but when they reviewed the transaction history, the resident did not recognize the name or phone number associated with the $300 transfer. A screenshot from the resident’s cell phone showed the $300 transfer to the housekeeper’s phone number. The resident reported that someone from activities obtained his debit card and that there were bank charges he did not recognize, which he reported to the Social Worker. The housekeeper admitted to helping set up the electronic transfer on the resident’s phone but denied taking the money or knowing how her number appeared on the transaction.
Failure to Follow Hand Hygiene Protocols During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during incontinence care for one resident. During an observation, a CNA assisted a male resident with severe cognitive impairment and multiple diagnoses, including dementia, neurogenic bladder, and muscle weakness, in changing his wet clothing and providing perineal care. The CNA put on gloves without performing hand hygiene, changed gloves multiple times without sanitizing hands, and continued to assist the resident and his roommate without following proper hand hygiene protocols. The facility's policies required hand hygiene before donning gloves, after glove removal, and when moving from dirty to clean tasks, but these procedures were not followed during the observed care. The resident involved required substantial assistance with personal hygiene due to his cognitive and physical limitations, as documented in his care plan and MDS assessment. Despite these needs and the facility's established policies, the CNA did not perform hand hygiene at any point during the care process, including after removing soiled gloves and before assisting another resident. This lapse in infection control practices was confirmed through interviews with the CNA and the DON, both of whom acknowledged the importance of hand hygiene and the failure to adhere to protocol during the incident.
Failure to Timely Report Resident-on-Resident Abuse and Injury
Penalty
Summary
The facility failed to ensure timely reporting of an alleged incident of neglect involving two residents. One resident, who had a history of Alzheimer's Disease and dementia with moderate cognitive impairment, was found with a swollen and red face, as well as a skin tear to the right elbow. The resident was unable to describe what had happened due to cognitive limitations. Documentation and interviews revealed that the resident was assessed, treated for pain, and sent for further medical evaluation. The incident was determined to have involved physical aggression from another resident, who was also observed with a swollen and bruised hand. Despite the facility's policy requiring immediate reporting of abuse, neglect, or injuries of unknown source to the state survey agency and other authorities, the incident was not reported as required. The DON and Administrator acknowledged that the event was not self-reported to the Texas Health and Human Services Commission. The Administrator stated the decision not to report was based on the belief that the altercation lacked intent to harm, given both residents' low BIMS scores and their placement in the memory care unit.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas, as observed during a survey. Six tomatoes in the walk-in refrigerator were found to be bruised, indicating improper storage and handling of produce. The Dietary Supervisor admitted to checking produce only weekly, which led to the oversight of bruised tomatoes. This failure in monitoring could lead to the use of compromised produce in meal preparation. During the lunch meal preparation and service, multiple instances of improper hand hygiene and inadequate use of hair restraints were observed among the dietary staff. Dietary staff members were seen not washing their hands before donning gloves and after handling food, which is against the facility's hand hygiene policy. Additionally, several staff members, including the Dietary Supervisor, were found with hair and facial hair not fully covered by their restraints, increasing the risk of contamination. Furthermore, the facility did not take the temperature of the second container of zucchini and gravy before serving them to residents, which is a violation of the facility's policy on food temperatures. The Dietary Supervisor and staff admitted to not checking the temperatures of these items, which could result in serving food at unsafe temperatures. These deficiencies collectively pose a risk of food-borne illness and contamination to the residents.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, particularly in the shower rooms across multiple hallways and in the provision of clean linens for a resident. Observations and interviews revealed that the shower rooms on several hallways were not cleaned thoroughly, with visible residues and unsanitary conditions present. Housekeeping staff were using an odor control solution instead of a sanitizing solution, which did not effectively sanitize the surfaces, thereby placing residents at risk of exposure to infectious diseases. The housekeeping supervisor was unaware of the misuse of cleaning solutions and the lack of a proper sanitizing solution in the supply closet. Additionally, the facility failed to provide clean linens for a resident with severe cognitive impairment and a productive cough. The resident was observed with soiled bed linens for an extended period, from 9:27 AM to 11:00 AM, without being changed. The CNA responsible for changing the linens acknowledged the delay and stated that it was unacceptable for the linens to remain soiled for that duration. The facility's policy required linens to be changed promptly when soiled to prevent infection and maintain a homelike environment. The facility's housekeeping policy and deep clean checklist did not adequately address the cleaning of shower rooms, contributing to the oversight in maintaining sanitary conditions. The lack of documentation and adherence to a deep cleaning schedule further exacerbated the issue, as the shower rooms were not cleaned to the facility's standard. The failure to use appropriate cleaning solutions and maintain cleanliness in both the shower rooms and resident linens posed a risk to resident health and safety.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #23, had access to a call light system that accommodated his needs and preferences. Resident #23, a male with moderate cognitive impairment and conditions including stroke, drug-induced subacute dyskinesia, and muscle wasting, was totally dependent on staff for activities of daily living. The resident's comprehensive care plan indicated a high risk for falls and required that his call light be within reach and usable. However, during observations, the call light was found clipped to the bed cover sheet at the level of his left shoulder, out of his reach, and he was unable to use it due to his involuntary hand movements. Interviews with RN A and the Director of Nursing (DON) confirmed that the call light should always be within reach and usable by the resident. RN A acknowledged that Resident #23 required a special call light due to his condition, but even with a flat call light provided, the resident was unable to use it. The Administrator also stated that the call light should be accessible before staff leave the room. The facility's policy on the call system emphasized the need for call cords to be within the resident's reach and for adaptive call bells to be provided as per the resident's needs. This deficiency placed the resident at risk of not being able to contact caregivers when needed.
Deficiencies in Resident Nail Care and Hygiene
Penalty
Summary
The facility failed to provide necessary services for two residents who were unable to perform activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #14, a female with severe cognitive impairment due to dementia, was observed with long and chipped fingernails, indicating a lack of proper nail care. Despite being on hospice care, the responsibility for her nail care was not adequately managed, as noted by RN A, who acknowledged the potential risk for infection and skin integrity issues. Similarly, Resident #31, a male with severe cognitive impairment and diabetes, was found with long, discolored, and dirty fingernails. CNA K admitted to not noticing the condition of the resident's nails, which posed a risk for infection and injury. The Director of Nursing (DON) confirmed that nail care should be performed as needed and observed daily, with specific protocols for diabetic residents. The facility's policy on grooming care was not adhered to, leading to these deficiencies in resident care.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by issues with the medication management on Nurses Cart Hall 100. RN C, who was responsible for this cart, did not remove medications from unsecure containers, which included broken blister packs for controlled medications such as hydrocodone acetaminophen and tramadol. These medications were found with broken seals, yet the pills remained inside the blister packs. RN C admitted to not checking the blister packs during the narcotics count at shift change and was unaware of who might have damaged the blisters. The Director of Nursing (DON) stated that any medication with a broken seal should be discarded to prevent drug diversion and infection control issues. Additionally, the facility failed to ensure that an expired insulin pen for a resident was removed from the cart. The insulin pen had an expired open date, which could lead to diminished effectiveness of the medication. RN C acknowledged not checking the insulin pen for the open date and stated that insulin is only effective for 28 days after opening. The DON confirmed that insulin pens need to be dated upon opening and discarded after their shelf life to maintain effectiveness. The facility's policies on medication storage and handling were not adhered to, as outdated or improperly stored medications were not immediately removed from inventory as required.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA J during incontinence care for Resident #9. On the observed date, CNA J, along with CNA B, entered the resident's room and began providing peri care. Although both staff initially washed their hands and donned gloves, CNA J did not change her gloves or perform hand hygiene after handling soiled materials and before touching clean items. Specifically, after cleaning the resident's anal area and handling a soiled draw sheet, CNA J placed a clean draw sheet and brief under the resident without changing her gloves, which is a breach of infection control protocols. The facility's policy on perineal care and hand hygiene clearly outlines the necessity of changing gloves and performing hand hygiene when transitioning from dirty to clean tasks. Despite this, CNA J failed to adhere to these guidelines, as confirmed by her own admission during an interview. The Director of Nursing (DON) acknowledged that staff are trained to change gloves and sanitize hands when moving from dirty to clean tasks, and recognized that the failure to do so increases the risk of infections. This incident highlights a lapse in following established infection control procedures, potentially placing residents at risk of cross-contamination and infection.
Misappropriation of Resident's Funds by Facility Employee
Penalty
Summary
The facility failed to protect a resident from misappropriation of property by an employee, identified as an Activities Assistant (AA). The Business Office Manager and Administrator discovered that AA had been using the resident's bank debit card for unauthorized transactions over several months, resulting in a loss of approximately $25,000 from the resident's personal bank account. The resident, who had a moderate cognitive impairment and a history of paranoid schizophrenia, had given his debit card and PIN to the AA to purchase cigarettes and food. However, the AA made unauthorized ATM withdrawals and purchases for personal use. The resident's care plan indicated communication problems and cognitive impairments, which may have contributed to his vulnerability. The Activity Director, who was responsible for overseeing the purchases made by the AA, failed to review the receipts, trusting the AA with the resident's bank card. This lack of oversight allowed the AA to exploit the resident's financial resources without detection. The Business Office Manager eventually discovered the unauthorized transactions while reviewing bank statements for Medicaid application purposes. The facility's policy on abuse prevention and prohibition was not effectively enforced, as the AA was able to misuse the resident's debit card for personal gain. The Administrator and Corporate Representative acknowledged that there was no system in place to monitor ATM cash withdrawals or other transactions for personal benefit, which allowed the misappropriation to occur. The facility's failure to protect the resident from financial exploitation highlights a significant deficiency in safeguarding resident property and ensuring staff accountability.
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.
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