Sorrento
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 2739 Babcock, San Antonio, Texas 78229
- CMS Provider Number
- 676378
- Inspections on file
- 37
- Latest survey
- November 30, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Sorrento during CMS and state inspections, most recent first.
The facility did not address or document group grievances raised by the resident council, including concerns about missing clothing, food service, and facility services. Staff interviews revealed confusion about the process for handling group grievances, and there was no evidence of investigation or communication of outcomes to the resident council, contrary to facility policy.
The facility did not complete or transmit required discharge MDS assessments for five residents, as shown by missing documentation in their electronic health records. This failure was identified during a review of MDS accuracy and completion, and it was found that the necessary discharge data was not submitted to the CMS system as required by policy and federal regulations.
A resident who required dialysis did not receive safe and appropriate dialysis care and services, as the facility failed to ensure the necessary care was provided.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not fully support residents' highest practicable physical, mental, and psychosocial well-being.
The facility did not ensure all residents were routinely offered suitable and nourishing snacks outside of scheduled meal times. Two residents reported not receiving snacks at night and expressed a desire for them, while staff confirmed snacks were mainly given to diabetics per physician orders, with leftovers provided only to those who asked. Staff did not proactively offer snacks to all residents, and facility records showed less than half of the residents were listed for evening snacks.
A resident with moderate cognitive impairment and partial mobility required assistance to use the restroom but was told by a CNA to use her brief instead of being assisted to the toilet. The resident's care plan called for encouraging self-care participation, and facility leadership confirmed that the CNA's actions did not meet expectations for resident dignity and respect.
A resident with multiple medical conditions and intact cognition had an OOH-DNR form that was not properly completed, as required signatures from the resident and witnesses were missing in the final section. Only the physician's signature was present, making the form invalid. The Social Worker acknowledged the oversight and responsibility for ensuring correct execution of advance directives, and the Administrator confirmed the expectation for accurate completion.
A resident with multiple chronic conditions was found to have a recliner in her room with a broken footrest and an exposed metal piece, which had not been reported or addressed for several days. The issue was only discovered after observation and interviews, revealing a lapse in maintaining a safe and comfortable environment as required by facility policy.
The facility did not develop and implement complete care plans with measurable actions and timetables to address all identified needs for sampled residents.
A resident with multiple chronic conditions was administered Hydralazine HCl on several occasions by LVNs despite their diastolic blood pressure being below the physician-ordered threshold. The facility's policy lacked guidance on medication parameters, and the DON confirmed that medications are expected to be given within set parameters or clarified with a physician if unclear.
A medication cart on one hall was left unattended and unlocked by an LVN due to a malfunctioning lock, with multiple medications accessible. The nurse did not report the malfunction, and the ADON was unaware of the issue. The DON stated that medication carts are expected to be locked when unattended and that malfunctions should be reported immediately. The facility did not provide a policy on medication cart security when requested.
A resident admitted for Covid-19 recovery was placed under droplet isolation precautions, but staff and a private caregiver entered the room wearing only surgical masks instead of the required N95 FFR. The PPE cabinet lacked N95 FFRs, and signage did not specify Covid-19-specific PPE requirements, leading to non-compliance with infection control protocols.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with severe cognitive impairment, respiratory failure, and mobility limitations did not receive care as outlined in her care plan. Staff transferred her using a gait belt instead of a mechanical lift and did not ensure her oxygen therapy was administered as ordered. These actions were inconsistent with physician orders and the resident's care plan.
A resident with severe cognitive impairment and significant mobility limitations was transferred from bed to wheelchair by two CNAs using a gait belt instead of the care-planned mechanical lift, due to the unavailability of a mechanical lift sling. Staff interviews confirmed the deviation from the care plan, and the facility administrator acknowledged the lack of a related policy.
A resident with severe cognitive impairment and a history of acute respiratory failure was not wearing oxygen tubing as ordered, despite medical orders and care plan interventions requiring continuous oxygen therapy. Observations and staff interviews confirmed the resident was not receiving oxygen as prescribed, and the facility's policy on oxygen administration was not followed.
A resident who required special eating equipment and utensils did not receive them, and appropriate assistance during meals was not provided.
Staff failed to immediately report multiple allegations of abuse and improper restraint involving a cognitively impaired, chair-bound resident. Incidents included a CNA yanking the resident from bed and making threats, as well as the resident's wheelchair being tied with trash bags to restrict movement. Several staff members observed or were informed of these events but did not escalate them to the administrator or authorities as required, resulting in delayed investigation and notification.
A CNA physically restrained a cognitively impaired, wheelchair-bound male resident by tying trash bags around his wheelchair wheels to restrict his movement after he was observed entering other rooms and taking items. The restraint was not medically indicated, not part of the care plan, and was not the least restrictive intervention. Staff observed the resident distressed and unable to move, and the incident was reported to facility leadership. Facility policy prohibits such restraints, and the event was not immediately reported to the state or administrator.
A resident with multiple health conditions was found with several unconsumed medications, including hydrocodone-acetaminophen and tamsulosin, left in their room. Nursing staff did not consistently verify that medications were swallowed and left medications at the bedside, contrary to facility policy. Additionally, the resident was repeatedly given the incorrect dosage of hydrocodone-acetaminophen due to staff not verifying the medication received from the pharmacy against the physician's order. Multiple nurses administered the wrong dose, and the error was only identified after review and interviews.
Nursing staff failed to consistently document the administration of hydrocodone-acetaminophen in the electronic medical record for a resident with multiple diagnoses and a pain management care plan. Although the medication was administered and signed out on the controlled drug record, entries were missing from the MAR, and staff interviews confirmed lapses in documentation as required by facility policy.
The facility's Dietary Services failed to maintain food safety and sanitation standards, with issues such as unsealed frozen food, gnats in the dry storage area, and unclean ice machines. The Nutritional Services Director and Registered Dietician acknowledged that improper cleaning and maintenance could lead to foodborne illnesses. A review of policies showed a cleaning schedule was in place but not followed.
A resident with multiple health issues developed new pressure ulcers while in a facility, but the family was not informed of these changes. Despite documentation indicating notification, staff interviews revealed confusion over responsibility for communication. The family only learned of the condition after a friend's visit, leading to the resident's hospital transfer.
A facility failed to ensure an accurate MDS assessment for a resident, incorrectly documenting a therapeutic diet instead of a regular diet. Interviews and record reviews confirmed the discrepancy, with staff acknowledging the outdated order and the importance of accurate documentation to prevent missed care.
The facility failed to update care plans for two residents, one with a supra-pubic catheter and another with PASRR services and an intellectual disability. These omissions could lead to missed or inaccurate care, as confirmed by staff interviews.
The facility failed to update care plans for two residents after assessments, leading to discrepancies in diet orders. One resident's care plan was not revised to reflect a change from a therapeutic to a regular diet, while another's did not accurately show a therapeutic and mechanically altered diet. Interviews confirmed the inaccuracies, which could result in missed care.
A facility failed to secure and label medications properly when an RN pre-poured Eliquis 25 mg for a resident and stored it in a medication cart after the resident was found sleeping. The medication was unlabeled, and the RN admitted that pre-pouring was against policy, risking incorrect administration. The resident's MAR did not document the medication as given.
The facility failed to properly dispose of garbage, leading to debris, including used incontinent briefs, around the dumpsters. The NSD noticed the overflow but did not clean it to avoid being late for a meeting, acknowledging the risk of attracting pests. The RD confirmed the need for a debris-free area to prevent pest entry. The facility's policy requires daily checks and reporting of debris.
A facility failed to maintain accurate medical records for a resident with multiple health issues, including a stage 4 pressure ulcer. The facility documented that the family was notified about wound assessments when they were not, as confirmed by RN C. This discrepancy could lead to miscommunication among staff, as noted by the DON. The facility's policy required accurate documentation of family notifications, which was not followed in this instance.
The facility failed to maintain an effective pest control program, leading to the presence of gnats in the kitchen's dry storage area. The NSD acknowledged not requesting pest control services, and interviews indicated that improper cleaning might have attracted the pests. The facility's pest control policy was not followed, as the Maintenance Supervisor was unaware of the issue until later, delaying intervention.
A facility failed to honor a resident's DNR order due to inadequate documentation and communication. The resident, with severe cognitive impairment, was admitted without proper acknowledgment of her DNR status, despite being a DNR in the hospital. Interviews revealed that the responsible party was not consulted about the code status, and the social worker failed to run necessary reports or communicate with the responsible party. The facility's policy on advance directives was not followed, resulting in the deficiency.
A facility failed to implement its admission policy for a cognitively impaired resident, leading to a deficiency. The resident, with severe cognitive impairment, was admitted without proper admission documents provided to her responsible party (RP). The admission packet was signed by the resident herself, despite her impairment, and completed five days post-admission. Interviews revealed discrepancies in understanding the resident's decision-making ability, with the RP expressing confusion and a lack of communication from the facility.
A facility failed to incorporate PASRR recommendations into a resident's care plan and did not submit required paperwork for specialized services on time. The resident, with Down Syndrome and severe cognitive impairment, was supposed to receive an air mattress and a custom wheelchair through PASRR. Despite receiving reminders, the MDS Nurse did not meet the submission deadlines, potentially delaying necessary services.
A newly admitted resident with cognitive impairment was not provided with a proper baseline care plan, leading to an incorrect code status being recorded. The resident's representative was not consulted about the code status, and the social worker failed to complete necessary advance directive paperwork. The facility's policy requiring a baseline care plan within 48 hours was not followed, resulting in potential risk to the resident's care.
A facility failed to update a resident's emergency contact information, listing a deceased family member despite the resident's severe cognitive impairment and available information. The CRC used hospital paperwork for contact details and acknowledged the resident's mention of the deceased family member during admission. The facility could not provide a policy for maintaining accurate medical records.
A resident was discharged from a facility without proper notification to her representative or the State LTC Ombudsman. Despite being cognitively intact and having no prior psychiatric issues, the facility refused her readmission after a hospital stay for an alleged suicide attempt. The facility did not provide the required written discharge notice or involve the Ombudsman, violating policy and regulatory requirements.
A resident was not readmitted to the facility after hospitalization due to an alleged suicide attempt, despite being medically cleared. The facility cited undisclosed suicidal ideation as the reason, failing to provide required notifications to the resident's representative and LTC Ombudsman, contrary to their policy.
Two residents with cognitive impairments were found with unsupervised access to disposable razors in their restrooms, posing a risk of injury. Despite no history of self-harm or aggression, the facility's staff, including the ADON and DON, acknowledged that these items should not have been accessible, highlighting a lapse in maintaining a safe environment as per the facility's safety policy.
The facility failed to include required information in 30-day discharge notices for three residents, omitting details such as the name, address, and contact information of the State Long-Term Care Ombudsman and the entity that receives appeal requests. This led to residents not being informed of their right to appeal or how to obtain assistance with the appeal process.
The facility failed to develop and implement effective person-centered discharge plans for three residents, resulting in 30-day discharge notices for unpaid balances without documented discharge plans or goals. The residents were not provided with appropriate assistance or viable discharge options that met their needs and preferences.
The facility failed to ensure that an LVN renewed his nursing license before expiration, resulting in him working for five days with an expired license. The HR Coordinator did not notice the expired license and did not communicate this to the DON or other management members. The issue was only addressed after surveyor intervention.
A resident with a history of heart failure, type 2 diabetes, and generalized osteoarthritis was improperly transferred to another facility while his Medicaid application was pending. The discharge notice lacked necessary information, and staff failed to communicate the resident's rights to appeal. Interviews revealed a lack of understanding and communication regarding the Medicaid application process and medical necessity determinations.
Failure to Address and Document Resident Council Grievances
Penalty
Summary
The facility failed to consider and act upon the views, grievances, and recommendations of the resident council regarding issues of resident care and life in the facility. Review of resident council meeting minutes from September through November showed that concerns such as missing clothing, food preferences, transportation issues, and problems with room landlines were documented, but there was no evidence of investigation, follow-up, or communication of results or rationale back to the resident council. The facility did not document responses or actions taken to address these group grievances, nor did it provide written decisions or maintain records as required by policy. Interviews with facility staff, including the DON, ADON, AED, and nursing staff, revealed that while individual grievances were generally addressed and documented, there was confusion and lack of clarity regarding the process for handling and documenting group grievances raised by the resident council. Staff members acknowledged that grievances brought up in resident council meetings should be addressed, but several were unsure whether these group grievances were documented or how they were resolved. The DON and other administrators indicated that they were not aware of the status or location of group grievance documentation for the months in question, and there was no system in place for tracking or responding to these concerns as a group. Facility policy required prompt resolution of grievances, written decisions, and maintenance of evidence regarding the results of all grievances. However, the lack of documentation and follow-up for resident council group grievances demonstrated a failure to comply with these requirements. This deficiency was identified through interviews, record reviews, and policy examination, which collectively showed that the facility did not ensure resident council concerns were investigated, resolved, or communicated back to the group as required.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System for five residents who were reviewed for MDS accuracy and completion. Specifically, discharge MDS assessments were not completed for these residents, as confirmed by record reviews of their electronic health records, which did not show a completed discharge MDS at least 30 days after each resident's discharge. This was identified for five out of twenty-four residents reviewed. Further review of the facility's policy and the RAI Manual confirmed that all MDS assessments, including discharge and reentry records, are required to be completed and electronically transmitted to the CMS QIES Assessment Submission and Processing (ASAP) system in accordance with OBRA regulations. The RAI Manual specifies that discharge assessments must be completed within 14 days after the discharge date. The facility did not adhere to these requirements for the identified residents, resulting in incomplete and untransmitted discharge MDS data.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided to meet the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the highest practicable physical, mental, and psychosocial well-being of each resident, as required.
Failure to Provide Suitable and Nourishing Snacks Outside Scheduled Meal Times
Penalty
Summary
The facility failed to ensure that all residents had access to suitable and nourishing meals and snacks outside of scheduled meal service times. Record review showed that the facility's meal schedule included only breakfast, lunch, and dinner, with no designated snack time. Observations and interviews revealed that residents were not routinely offered snacks at bedtime, and some residents expressed a desire for snacks at night but were hesitant to request them directly. Specifically, two residents reported not receiving snacks at night and indicated they would like to be offered snacks when hungry outside of regular meal times. Interviews with facility staff, including the ADM, ADON, and Certified Dietary Manager, confirmed that snacks were primarily distributed to diabetic residents based on physician orders, with any remaining snacks given to those who requested them. Staff did not proactively offer snacks to all residents or visit each room to ensure residents had the opportunity to receive a snack. The facility's records indicated that only 39 out of 96 residents were listed for an evening snack, and the policy for snack distribution was requested but not provided at the time of the survey.
Resident Denied Dignified Toileting Assistance by CNA
Penalty
Summary
A certified nursing assistant (CNA) failed to honor a resident's request to be taken to the restroom, instead instructing the resident to use her brief and stating she would return later to change her. This occurred despite the resident having no impairment in her upper or lower extremities, using a walker for mobility, and requiring only partial to moderate assistance for sit-to-stand transfers. The resident's care plan included encouraging participation in self-care to the fullest extent possible. The resident was observed vocalizing in her room with her call light on when the CNA responded and gave the instruction to use the brief. Interviews with the CNA, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that the expectation was to assist residents to the restroom if they requested and were able to transfer safely. The ADON and DON both acknowledged that telling a resident to use their brief instead of assisting them to the restroom was a dignity concern and not acceptable. Facility policy required all employees to treat residents with kindness, respect, and dignity.
Failure to Ensure Valid Completion of OOH-DNR Form
Penalty
Summary
A deficiency occurred when a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was found to be incomplete and therefore invalid. The resident, who had diagnoses including paraplegia, cirrhosis of the liver, and sepsis, was documented as having intact cognition and had requested a DNR status. The resident's care plan and face sheet both indicated a DNR order, and the OOH-DNR form was present in the record. However, upon review, it was discovered that the required signatures in the final section of the OOH-DNR form were missing for the resident and the witnesses, with only the physician's signature present. The form's instructions specified that all parties who signed above must also sign below to acknowledge proper completion. During interviews, the Social Worker confirmed that the missing signatures rendered the OOH-DNR form invalid and acknowledged responsibility for ensuring the correct execution of such forms. The Administrator also confirmed the expectation that all OOH-DNR forms be fully and accurately completed. Facility policy required verification of advance directive documentation for accuracy, and state guidance indicated that improperly completed forms may not be honored by health professionals.
Broken Recliner with Exposed Metal Piece in Resident Room
Penalty
Summary
A deficiency was identified when a resident's recliner was found to have a broken footrest with a metal piece protruding from it, which is part of the mechanical system that supports the footrest. The resident, who had diagnoses including muscle wasting and atrophy, COPD, type 2 diabetes, and hypothyroidism, and who was cognitively intact, reported that the recliner had been broken since being moved into the room several days prior. The resident had not reported the issue to staff and stated that she had not been injured because she was careful to avoid the exposed metal. Observation and interviews confirmed that the broken recliner was present in the resident's room until it was discovered by staff. The facility's policy requires a clean, sanitary, and orderly environment, but the broken recliner with an exposed metal piece was not identified or addressed by staff until it was brought to their attention. This failure resulted in the resident being exposed to an environment that was not safe, functional, or comfortable, as required by facility policy.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
A deficiency was identified regarding the development and implementation of a complete care plan that meets all the resident's needs, including measurable timetables and actions. The report indicates that the facility failed to ensure that care plans were comprehensive and addressed all identified needs for the residents sampled. Specific details about the number of residents sampled and cited are not provided in the excerpt, nor are individual resident conditions or medical histories described.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors. The resident, who had diagnoses including muscle wasting and atrophy, COPD, type 2 diabetes, hypothyroidism, and hypertension, was prescribed Hydralazine HCl with specific parameters: the medication was to be held if the systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate was under 60 beats per minute. Despite these parameters, the medication was administered on four occasions when the resident's diastolic blood pressure was below 60. Record review showed that the medication was given outside of the prescribed parameters by two LVNs on multiple dates. The facility's medication administration policy did not include guidance regarding medication parameters. During an interview, the DON stated that medications should be given within parameters and that staff should contact the physician if parameters are unclear.
Unattended and Unlocked Medication Cart Due to Malfunctioning Lock
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all drugs and biologicals were stored securely and locked in accordance with professional standards. During an observation, a medication cart assigned to the 800 hall was found unattended and unlocked in a hallway, with drawers containing various medications such as acetaminophen, aspirin, docusate, and vitamin C accessible. The nurse assigned to the cart, an LVN, stated that the lock on the cart had malfunctioned and had not reported the issue since the start of her shift, assuming the facility was already aware of the problem. The cart remained unsecured and unattended, out of the nurse's line of sight, allowing potential unauthorized access to medications. Interviews with facility staff revealed that the ADON was not aware of the malfunctioning lock, and the DON confirmed that the expectation is for medication carts to be locked whenever unattended, with immediate reporting required for any malfunctions. Despite a request, the facility did not provide a policy regarding medication cart security by the time of the report. The failure to secure the medication cart and promptly report the malfunction led to a lapse in the safe storage of drugs and biologicals.
Failure to Provide Required PPE for Covid-19 Isolation Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident who was admitted with a diagnosis of Covid-19 and placed under droplet isolation precautions per physician order. Observations revealed that housekeeping staff entered the resident's room wearing a surgical mask, gown, gloves, and face shield, but not the required N95 filtering facepiece respirator (FFR) as specified for Covid-19 precautions. The signage outside the resident's room indicated droplet precautions but did not specify the need for N95 FFR for Covid-19, and the PPE storage cabinet outside the room did not contain any N95 FFRs. The private caregiver present in the room was also observed wearing only a surgical mask and reported not being trained on appropriate PPE use for the situation. Interviews with facility staff, including the ADON, LVN, and DON, confirmed that the resident was under Covid-19 isolation precautions and that all staff entering the room should have worn an N95 FFR. Staff acknowledged the absence of N95 FFRs in the designated PPE cabinet and the lack of clear signage specifying Covid-19-specific PPE requirements. The facility's failure to provide appropriate PPE and clear instructions for staff and visitors resulted in non-compliance with CDC infection control guidance for Covid-19.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or record review, indicating that the required protocols for protecting confidential information or properly maintaining medical records were not followed as expected. No additional details regarding specific residents, staff actions, or the exact nature of the records involved are provided in the report.
Failure to Implement Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical needs, including acute respiratory failure with hypoxia, dementia, and significant mobility limitations. The care plan specified that the resident required oxygen therapy at 2-4 liters per nasal cannula and mechanical lift transfers with two-person staff assistance. However, staff did not follow the care plan during observed care. On one occasion, two CNAs transferred the resident from bed to wheelchair using a gait belt instead of the required mechanical lift, citing the unavailability of a mechanical lift sling. Both CNAs acknowledged that the resident typically required a mechanical lift and that the deviation from the care plan was reported to the charge nurse. Additionally, the resident was observed on multiple occasions without her oxygen tubing in place, despite physician orders and care plan directives for continuous oxygen therapy. The oxygen tubing was found lying across the bed or not on the resident's nasal area while she was in her wheelchair and eating lunch. The resident stated she only wore the oxygen at night, and the ADON confirmed the resident was not wearing the oxygen as ordered, with no documented response to the risk. The facility's policy required care plans to be updated to reflect oxygen use, but there was no evidence this was consistently implemented.
Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including acute respiratory failure, dementia, and muscle weakness, was not transferred according to her care plan. The care plan specified that the resident required a mechanical lift with two-person staff assistance for transfers due to her mobility limitations and dependence on assistive devices. However, during an observed transfer, two CNAs used a gait belt instead of the mechanical lift because a mechanical lift sling could not be located. The mechanical lift was present in the room, but the necessary sling was missing, leading staff to proceed with a manual transfer using a gait belt. Interviews with the involved CNAs confirmed that the resident was typically transferred with a mechanical lift, but due to the unavailability of a sling, they used a gait belt for the transfer. One CNA reported the deviation from the care plan to the charge nurse. The physical therapist noted that the resident's ability to transfer could vary depending on her anxiety or pain levels, but at the time of the incident, the care plan still required a mechanical lift. The facility administrator and DON acknowledged the risk associated with not following the care plan and stated there was no policy in place regarding this situation.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure with hypoxia, pneumonia, cognitive impairment, and dependence on oxygen therapy was not provided oxygen as ordered. The resident's medical orders specified oxygen at 2-4 liters per nasal cannula every shift, and the care plan included interventions to provide oxygen as ordered. Observations revealed that the resident was not wearing her oxygen tubing on two separate occasions, with the tubing found lying across her bed and not in use while she was eating lunch. Interviews confirmed that the resident only wore her oxygen tubing at night, and staff acknowledged that the oxygen tubing was not in place as ordered. Further interviews with the ADON and DON confirmed the lack of adherence to the oxygen order, with the DON updating the care plan to note the resident's tendency to remove the tubing. The facility's policy required care plans to reflect oxygen use and proper storage of cannulas when not in use. The failure to ensure the resident received oxygen therapy as ordered was identified through observations, interviews, and record reviews.
Failure to Provide Special Eating Equipment and Assistance
Penalty
Summary
A deficiency was identified when the facility failed to provide special eating equipment and utensils for residents who required them, as well as appropriate assistance during meals. This inaction resulted in residents not receiving the necessary support to eat safely and effectively, as directly observed by surveyors.
Failure to Timely Report Alleged Abuse and Improper Restraint
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—were reported immediately to the administrator and appropriate authorities as required. Multiple staff members observed or were informed of incidents involving a resident with severe cognitive impairment, hemiplegia, and a history of falls, but did not report these allegations in a timely manner or to the correct individuals. Specifically, a CNA witnessed another CNA yanking the resident out of bed and threatening to kill him in Spanish, but did not report this to the administrator and delayed reporting to other supervisors. Another CNA observed the resident's wheelchair wheels tied together with plastic bags, restricting mobility, but did not escalate the incident to the DON or administrator, relying instead on the assumption that another nurse had reported it. Further, the DON and UM were notified by an LVN that the resident had been restrained with trash bags on his wheelchair, but neither reported the allegation to the administrator as required by facility policy and federal regulations. Interviews revealed confusion and lack of clarity among staff regarding reporting protocols, with some staff unsure of who the administrator was or how to contact them. Documentation confirmed that staff had received training on abuse prevention and reporting, and had signed policies outlining their responsibilities, yet failed to act according to these protocols when faced with actual incidents. The resident involved was highly vulnerable due to severe cognitive impairment, hemiplegia, and a high risk of falls, requiring substantial assistance for daily activities. Despite this, staff failed to report and escalate serious allegations of abuse and improper restraint, including physical handling and threats, as well as the use of makeshift restraints that restricted the resident's primary mode of mobility. These failures resulted in a lack of timely investigation and notification to state authorities, as required by both facility policy and federal regulations.
Resident Restrained with Trash Bags on Wheelchair Wheels
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically restrained a male resident with severe cognitive impairment, hemiplegia, and a history of falls by tying trash bags around the wheels of his wheelchair. This action was taken to restrict the resident's independent mobility after he was observed roaming the halls, entering other residents' rooms, and taking items from the nurse's station. The restraint was not ordered for medical treatment, was not documented in the care plan, and was not the least restrictive intervention. Multiple staff members observed the resident unable to move his wheelchair, appearing distressed and agitated, and attempting to reach for items while restrained. The incident was witnessed by a licensed vocational nurse (LVN), who intervened by cutting the trash bags off the wheelchair and reported the event to facility leadership. Other staff members also became aware of the restraint, with some expressing concern that it constituted abuse and should have been reported immediately. The CNA involved admitted to placing the trash bags on the wheelchair wheels to slow the resident down, acknowledging prior training on restraints and abuse, but did not perceive his actions as a restriction at the time. Facility records and staff interviews confirmed that the resident's care plan did not include the use of restraints, and the facility's policy promoted restraint-free care. The resident's primary mode of mobility was his wheelchair, and the restraint directly impeded his ability to move freely. The event was not immediately reported to the state, and there was a lack of timely notification to the facility administrator. The deficiency was identified based on staff interviews, resident records, and review of facility policies, which all indicated that the use of physical restraints in this manner was not permitted and violated the resident's right to dignity and freedom from unnecessary restraint.
Failure to Ensure Accurate Medication Administration and Dosage Verification
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration and consumption of medications for a resident with multiple diagnoses, including metabolic encephalopathy, anxiety disorder, and acute kidney failure. Observations revealed that the resident had multiple medication cups and loose pills, including hydrocodone-acetaminophen and tamsulosin, left in his room and not consumed as intended. Nursing staff admitted to leaving medications at the bedside and not verifying that the resident had actually swallowed the medications, despite being trained to do so. The resident was cognitively intact and had a history of rejecting care, but staff did not consistently follow procedures to ensure medication administration was completed as required. Additionally, the facility failed to ensure the resident received the correct dosage of hydrocodone-acetaminophen as prescribed by the physician. The physician's order was for 10/325 mg, but the resident was administered 5/325 mg tablets on multiple occasions. This discrepancy occurred after a new prescription was filled by the pharmacy, and nursing staff did not verify the medication received against the physician's order. Multiple nurses administered the incorrect dosage, assuming the medication on hand was correct, and did not clarify the discrepancy with the physician or pharmacy. The error was only discovered after review and interviews with staff and pharmacy personnel. Interviews with nursing staff and administration confirmed that the facility's policy required verification of the right dose and observation of medication consumption, but these procedures were not followed. Staff acknowledged being aware of the resident's behaviors and the need for careful administration but failed to adhere to established protocols. The facility's Director of Nursing and Assistant Director of Nursing both stated that medications should not be left at the bedside and that the correct dosage must be verified before administration, but these expectations were not met in practice.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, documentation of the administration of hydrocodone-acetaminophen (Norco) was missing from the electronic medical record (MAR) for several dates, despite the medication being signed out on the controlled drug record. Multiple nurses, including LVNs, administered the medication but did not consistently document the administration in the electronic medical record as required by facility policy. Interviews with nursing staff confirmed that the medication was given but not always recorded in the MAR, with one LVN admitting to forgetting to document after administration. The resident involved was a cognitively intact male with diagnoses including metabolic encephalopathy, anxiety disorder, and acute kidney failure, and had a care plan for pain management that included active participation in care decisions. The resident reported that his pain was well controlled and that the medication was essential for him. The facility's policy required documentation of medication administration in the MAR after the resident took the medication, but this was not consistently followed, resulting in incomplete medical records for the resident.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility's Dietary Services failed to adhere to professional standards for food service safety, as evidenced by several observations and interviews. During an initial tour, it was noted that the kitchen freezer contained packages of frozen pork sausage patties and chicken nuggets that were opened and not sealed, which the Nutritional Services Director (NSD) acknowledged could lead to freezer burn and contamination. Additionally, gnats were observed flying in the dry storage area, and the NSD admitted that this might be due to unclean drains. The ice machine in the kitchen had a black substance in the area where ice was dispensed, and hard water stains were present on the outside. Similar issues were found in the nutrition room of the [NAME] Neighborhood, where the ice machine also had a black substance on the hood, and food in the freezer was unlabeled. Interviews with the NSD and the Registered Dietician highlighted concerns about improper cleaning and maintenance practices that could lead to foodborne illnesses. The NSD admitted that the dietary staff was responsible for cleaning the fridges and ice machines, but these tasks had not been completed as required. The Registered Dietician emphasized the importance of keeping the kitchen clean to prevent foodborne illnesses and noted that improper food storage could lead to cross-contamination. A review of the facility's policies revealed that there was a comprehensive cleaning schedule in place, but it was not being followed, contributing to the observed deficiencies.
Failure to Notify Resident Representative of Condition Changes
Penalty
Summary
The facility failed to immediately notify the resident representative of significant changes in the resident's condition, specifically the development of multiple facility-acquired pressure ulcers. The resident, a male with a history of multiple serious health conditions including stage 4 pressure ulcers and diabetes, was admitted to the facility from an acute care hospital. Despite the resident's care plan indicating the need for notification of changes in condition, the facility did not inform the resident's representative of new pressure ulcers that developed over a 12-day period. The resident's medical records showed that he had several pre-existing conditions upon admission, including a stage 4 sacral ulcer and unstageable deep tissue injuries. However, during his stay, additional pressure ulcers developed on various parts of his body, which were not communicated to his family or representative. The resident's family only became aware of the worsening condition and new wounds after a visit from a family friend, which led to the resident being sent to the hospital for further evaluation. Interviews with facility staff revealed confusion and lack of clarity regarding who was responsible for notifying the family about changes in the resident's condition. The wound care nurse and other staff members admitted to not notifying the family, despite documentation suggesting otherwise. This lack of communication resulted in the family being unaware of the resident's declining condition, leading to distress and a decision to transfer the resident to a hospital for further care.
Inaccurate MDS Assessment for Resident's Diet
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for one resident reviewed for MDS assessments. Specifically, the quarterly MDS assessment for a resident inaccurately indicated that the resident was on a therapeutic diet, while the resident was actually ordered a regular diet. This discrepancy was identified through interviews and record reviews, which revealed that the resident's comprehensive care plan also inaccurately reflected a therapeutic diet. The resident's electronic medical record and diet orders confirmed that a regular diet had been ordered, and the resident was observed consuming a regular meal. Interviews with facility staff, including an RN and the DON, confirmed that the MDS and care plan were not updated to reflect the resident's current diet order. The RN acknowledged that the NSOT order was outdated and that the regular diet was the accurate order. The DON emphasized the importance of accurate MDS and care plans to prevent missed care. The CMS Long-Term Care Facility Resident Assessment Instrument manual underscores the regulatory requirement for assessments to accurately reflect the resident's status.
Failure to Update Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which could lead to missed or inaccurate care. Resident #35, who was admitted with diagnoses including dysphagia, vascular dementia, and neuropathic bladder, had a supra-pubic indwelling urinary catheter that was not reflected in her current care plan. Despite the catheter being active since February 2024, the care plan was not updated to include this critical aspect of her care. This oversight was confirmed through interviews with RN A and the DON, who acknowledged the necessity of updating the care plan to accurately reflect the resident's needs. Similarly, Resident #71, who was admitted with conditions such as heart disease, disorders of the peritoneum, atrial fibrillation, and an intellectual disability, did not have his PASRR services or intellectual disability documented in his care plan. The admission MDS assessment indicated a positive PASRR level II screening, yet this was not incorporated into the care plan. Interviews with RN A and the DON highlighted the importance of including these details to ensure the resident's care needs are met and not overlooked. The facility's policy on comprehensive care planning emphasizes the need for care plans to include measurable objectives and time frames based on comprehensive assessments, which was not adhered to in these cases.
Failure to Update Care Plans After Assessments
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were reviewed and revised by the interdisciplinary team after their respective assessments. Resident #15's care plan was not updated following a quarterly MDS assessment to reflect a change from a therapeutic diet to a regular diet, despite the diet order being changed months prior. Observations and interviews confirmed that the resident was receiving a regular diet, and both the RN and DON acknowledged the care plan's inaccuracy, which could lead to missed care. Similarly, Resident #70's care plan was not revised after an annual MDS assessment to accurately reflect the resident's therapeutic and mechanically altered diet. The resident's diet order had been updated to LCS pureed, but the care plan still contained outdated information. Interviews with the RN and DON confirmed the need for revision to prevent potential care discrepancies. The CMS MDS 3.0 Manual mandates that care plans be reviewed and revised after each assessment, highlighting the facility's failure to comply with these requirements.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper security and labeling of drugs and biologicals within one of the four medication carts observed. During an observation, a medication cup containing an unlabeled small yellow pill was found in the top drawer of a locked medication cart in hallway 100. RN B admitted to pre-pouring the medication, identified as Eliquis 25 mg for a resident, and storing it in the cart when the resident was found sleeping. RN B acknowledged that pre-pouring medications was against facility policy and could lead to residents not receiving their medications as prescribed or the wrong resident receiving the medication. A review of the resident's Medication Administration Record (MAR) showed that the medication was not documented as given. The facility's policy on medication storage requires drugs to be stored in their original packaging or dispensing systems.
Improper Garbage Disposal Leading to Potential Pest Infestation
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, compromising the cleanliness and safety of the environment for residents. Observations on 7/23/2024 revealed garbage, including used incontinent briefs and plates, scattered on the ground around the dumpsters located at the back of the building near the kitchen doors. During an interview, the Nursing Services Director (NSD) acknowledged the overflow of garbage and stated that when the garbage truck emptied the dumpsters, some garbage fell onto the ground. The NSD admitted to noticing the garbage before a morning meeting but chose not to clean it to avoid being late. She recognized that leaving garbage on the ground could attract pests and rodents. The Registered Dietitian (RD) confirmed that the dumpster area should be free from debris to prevent pests and rodents from entering the building. A review of the facility's Dumpster Protocol policy, dated 12/2023, indicated that the dumpster area should remain free of debris, with the Director of Maintenance or a designee responsible for daily checks. Additionally, any facility staff observing debris should report it to the Executive Director or Director of Maintenance.
Failure to Accurately Document Family Notifications for Resident Wound Care
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident #96, which is a violation of accepted professional standards and practices. The deficiency was identified through observation, interview, and record review. Specifically, the facility documented that the family of Resident #96 was notified about wound assessments when, in fact, they were not. This discrepancy was confirmed by RN C, who admitted to documenting family notifications that did not occur due to time constraints. Resident #96 was a male admitted to the facility with multiple serious health conditions, including a stage 4 pressure ulcer, type 2 diabetes, and a gastrostomy malfunction. The resident was cognitively intact but had limited mobility and was dependent on assistance for various activities. During the resident's stay, several new deep tissue injuries developed, and the family expressed concerns about the resident's worsening condition and lack of communication regarding these changes. Interviews with staff, including RN C and the Director of Nursing (DON), revealed that the failure to notify the family as documented could lead to miscommunication among staff. The facility's policy on charting and documentation required that family notifications be accurately recorded, which was not adhered to in this case. This failure in documentation could result in confusion and decreased continuity of care for the resident.
Deficient Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in the dry storage area of the kitchen. During an observation, approximately five gnats were seen flying around food items on the top shelf, near packages of pasta and dry foods. This issue was identified during a survey on July 23, 2024, at 9:30 AM. The Nutrition Services Director (NSD) acknowledged the presence of the gnats and admitted that she had not requested pest control services for this issue, indicating a lapse in the facility's pest control procedures. Interviews with the NSD and the Registered Dietician revealed that the gnats might have been attracted due to improper cleaning, possibly from the kitchen drains. Both staff members expressed concerns that the presence of gnats could lead to foodborne illnesses among residents. A review of the facility's pest control policy, dated November 3, 2004, outlined a procedure for reporting pest sightings, which was not followed in this instance. The Maintenance Supervisor confirmed that the pest control service was scheduled to visit monthly and as needed, but he was not informed of the gnat issue until the day of the interview, preventing timely intervention.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order, which is a critical aspect of respecting residents' rights to formulate advance directives. The resident in question was a female with severe cognitive impairment, admitted with conditions including hemiplegia, cerebrovascular disease, and seizures. Despite being a DNR in the hospital, the facility's records did not reflect this status. The resident's face sheet, admission MDS assessment, baseline care plan, comprehensive care plan, and order summary report all lacked documentation of an advanced directive or code status order. The admission packet was signed by the resident, who was not in a position to make informed decisions, and the pages containing DNR information were unsigned. Interviews with the resident's responsible party (RP) and facility staff revealed systemic failures in the process of documenting and honoring advance directives. The RP was not consulted about the resident's code status upon admission, and attempts to communicate with the social worker (SW) were unsuccessful. The SW admitted to not running the necessary reports to identify residents needing code status orders and was unaware of the resident's DNR status. The Director of Nursing (DON) confirmed that without an advanced directive, CPR would be performed, which contradicts the resident's wishes. The facility's policy required acknowledgment of advance directives upon admission and regular review, but these procedures were not followed, leading to the deficiency.
Failure to Implement Admission Policy for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement its admission policy for a resident, resulting in a deficiency. The resident, a female with severe cognitive impairment due to hemiplegia following a nontraumatic subarachnoid hemorrhage, cerebrovascular disease, and seizures, was admitted without the proper admission documents being provided to her responsible party (RP). The admission packet was signed by the resident herself, despite her severe cognitive impairment, and was completed five days after her admission. The resident's face sheet indicated that she was her own RP, but her advanced directive was left blank. Interviews revealed discrepancies in the understanding of the resident's ability to make decisions. The resident's RP stated that they did not complete any paperwork upon admission and expressed confusion about the resident's care plan. The RP also mentioned a lack of communication from the facility. A Licensed Vocational Nurse (LVN) noted that the resident's responses were inappropriate and that she should not be her own RP. The facility's Clinical Resource Coordinator (CRC) claimed that the resident understood the admission packet and signed it herself, while the RP denied refusing to sign any paperwork. The facility's policy requires that all residents have a signed and dated admission agreement on file, which was not adhered to in this case.
Failure to Incorporate PASRR Recommendations and Submit Required Paperwork
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and evaluation report into the assessment, care planning, and transitions of care for a resident with Down Syndrome and other medical conditions. The resident, who was severely impaired for cognitive skills, was identified as PASRR positive. Despite discussions by the IDT team to obtain an air mattress through PASRR, the vendor did not come, and the facility provided an overlay air mattress instead. Additionally, paperwork for a custom wheelchair was submitted, but the facility did not have an expected delivery date. The MDS Nurse admitted to receiving several emails and phone calls from the PASRR office but failed to submit the required paperwork by the due date, which was within 20 days of the IDT care plan meeting. The facility needed to submit NFSS forms for PASRR Specialized Services for a mattress and a customized manual wheelchair by specific deadlines, which were missed. This failure could place residents at risk for not receiving specialized services in a timely manner.
Failure to Implement Baseline Care Plan and Confirm Code Status
Penalty
Summary
The facility failed to implement a baseline care plan for a newly admitted resident, which included the necessary instructions to provide effective and person-centered care. The resident, a cognitively impaired elderly female with a history of hemiplegia, cerebrovascular disease, and seizures, was admitted without a clear code status documented. The face sheet and comprehensive care plan lacked advanced directive information, and the baseline care plan incorrectly listed the resident as a full code without proper authorization or signature from the resident or their representative. Interviews revealed that the resident's representative was not consulted about the code status upon admission, and the social worker had not completed the necessary paperwork for advance directives. The representative expressed confusion and frustration over the lack of communication and stated that the resident was a DNR in the hospital. The social worker admitted to not being aware of the resident's DNR status and had not spoken to the representative, citing a busy workload as a reason for the oversight. The facility's policy required a nursing assessment and a baseline care plan to be completed within 48 hours of admission, including details such as code status. However, the social worker and other staff failed to adhere to these protocols, resulting in a lack of clarity and potential risk for the resident's care. The Director of Nursing confirmed that without an advanced directive, staff would perform CPR, which could contradict the resident's wishes if they were a DNR.
Failure to Update Emergency Contact Information
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the update of emergency contact information. The resident, a female with severe cognitive impairment due to conditions such as hemiplegia following a nontraumatic subarachnoid hemorrhage, cerebrovascular disease, and seizures, had outdated emergency contacts listed on her face sheet. The listed contacts included a deceased family member, which was not updated despite the resident's cognitive limitations and the information being available to the facility staff. During an interview, the CRC admitted to using hospital paperwork to fill out the emergency contact information and acknowledged that the resident had mentioned the passing of the family member during the admission process. However, the CRC stated that in an emergency, they would contact the other family member listed before the deceased one. The facility was unable to provide a policy for the accuracy of medical records when requested, indicating a lack of adherence to professional standards in maintaining resident records.
Failure to Notify Resident and Ombudsman of Discharge
Penalty
Summary
The facility failed to provide timely and appropriate notification to a resident, her representative, and the State Long-Term Care Ombudsman regarding the resident's discharge. The resident, a female with a history of spondylosis, vascular dementia, and borderline personality disorder, was admitted to the hospital after an alleged suicide attempt involving bleach ingestion. Despite being cognitively intact and having no documented history of psychiatric issues or suicidal ideation, the facility decided not to readmit her after her hospital stay, citing safety concerns. The facility did not provide written notification of the discharge to the resident's representative or the Ombudsman, as required by policy. The resident's representative was informed verbally by the Director of Nursing (DON) that the facility would not readmit the resident due to her disclosed history of suicidal ideation. This decision was made without providing the required 30-day notice or documenting the discharge in writing, which is a violation of the facility's policy and regulatory requirements. Interviews with the resident's representative and facility staff revealed that the resident was unhappy with the care she received and had expressed frustration, leading to the alleged suicide attempt. The facility's failure to notify the Ombudsman and provide written discharge notices could disrupt the resident's care continuity and violate her rights to appeal the discharge decision. The facility's policy requires that such notices be given in a timely manner and in a language and form that the resident and their representative can understand, which was not adhered to in this case.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to establish and follow a written policy on permitting residents to return after hospitalization, specifically in the case of a resident who was not readmitted following a hospital stay. The resident, a female with a history of spondylosis, vascular dementia, and borderline personality disorder, was sent to the hospital after an alleged suicide attempt involving bleach. Despite being medically cleared for discharge and expressing a desire to return to the facility, the resident was not readmitted. The facility's decision not to readmit the resident was based on newly disclosed information about her history of suicidal ideation, which was not documented prior to her hospitalization. The facility's Director of Nursing (DON) informed the resident's representative that the facility would not take her back, citing the resident's past suicidal ideation as the reason. This decision was made without providing the required written notification to the resident's representative or the LTC Ombudsman, as stipulated by the facility's policy. Interviews with facility staff revealed that the decision not to readmit the resident was influenced by the contentious relationship between the resident and her representative, as well as the facility's lack of awareness of her psychiatric history. The facility's policy required that residents sent to acute care settings be allowed to return unless their health or safety, or that of others, would be endangered. However, the facility did not provide the necessary documentation or follow the proper procedures for discharge, resulting in a deficiency in their handling of the resident's case.
Failure to Prevent Access to Hazardous Items
Penalty
Summary
The facility failed to maintain a safe environment for two residents by allowing them unsupervised access to disposable razors, which posed a risk of injury. Resident #2, who has vascular dementia with behavioral disturbance and moderate cognitive impairment, was found with 15 disposable razors and a pair of scissors in his restroom drawer. Despite having no history of suicidal ideation or aggression, the presence of these items was confirmed by the Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN), who acknowledged that Resident #2 should not have unsupervised access to such sharp objects. Similarly, Resident #3, diagnosed with paranoid schizophrenia, dementia, and severe cognitive impairment, was found with 5 disposable razors in his restroom drawer. Although Resident #3 also denied any thoughts of self-harm or harm to others, the ADON and LVN confirmed that these razors should not have been accessible to him. The Director of Nursing (DON) agreed that the razors should not have been present given the residents' diagnoses, acknowledging the potential risk of injury. The facility's policy on safety and supervision, revised in 2017, emphasizes the importance of resident supervision based on individual needs and environmental hazards. However, the presence of razors in the residents' restrooms indicates a lapse in adhering to this policy, as the facility did not adequately assess and mitigate the potential hazards posed by these items in the residents' environment.
Failure to Include Required Information in Discharge Notices
Penalty
Summary
The facility failed to ensure that 30-day discharge notices included a statement of the resident's right to appeal, which should have included the name, address (mailing and email), and telephone number of the entity that receives such requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. This deficiency was identified for three residents who were reviewed for discharge. The notices also lacked the name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman. Resident #1, who had diagnoses including type 2 diabetes mellitus with complications and end-stage renal disease, received a discharge notice that did not include the required information. The resident expressed a desire to remain in the facility due to her medical needs and had previously attempted to appeal a discharge notice with the Ombudsman, but no action was taken. The resident's comprehensive care plan did not include a plan or goals for discharge. Resident #2, who was admitted with diagnoses such as obstructive and reflux uropathy and chronic kidney disease, also received a deficient discharge notice. The resident was cognitively intact and had not achieved her goal of walking, remaining bed-bound. She had previously sought help from the Ombudsman but did not appeal the current discharge notice due to a lack of information and assistance from the facility. Similarly, Resident #3, who had heart failure and type 2 diabetes mellitus, received a discharge notice without the required information. The resident was transferred to another facility without understanding his right to appeal. Interviews with the facility staff revealed a lack of knowledge and communication regarding the discharge process and residents' rights to appeal.
Failure to Implement Effective Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective person-centered discharge plan for three residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental and psychosocial needs. Resident #1, who had moderate cognitive impairment and required assistance due to renal dialysis, was given a 30-day discharge notice for an unpaid balance without a discharge plan or goals documented in her care plan. Despite her desire to remain in the facility and her communication with the Ombudsman, no effective discharge planning was conducted, and she was not provided with appropriate assistance to address her unpaid balance or alternative arrangements that met her needs. Resident #2, who was cognitively intact but bed-bound due to a severe infection, also received a 30-day discharge notice for nonpayment. She had not achieved her goal of walking and was not provided with a discharge plan or goals in her care plan. Despite her refusal to apply for Medicaid to avoid losing her house, the facility did not engage in effective discharge planning or provide her with viable options that met her needs and preferences. She expressed uncertainty about her discharge options and felt unsupported by the facility. Resident #3, who had moderate cognitive impairment and was wheelchair-bound after completing therapy services, was transferred to another nursing facility without a documented discharge plan or goals in his care plan. He was given a 30-day discharge notice for an unpaid balance and was unaware of the plans until the transfer occurred. The facility's social worker and MDS Coordinator acknowledged the lack of discharge planning documentation and the importance of including discharge planning in comprehensive care plans, but no effective measures were taken to address the residents' needs and preferences for discharge.
Failure to Ensure Nursing License Renewal
Penalty
Summary
The facility failed to ensure that LVN A renewed his nursing license before the expiration date, resulting in him practicing nursing with an expired license. This was discovered through record review, observation, and interviews. LVN A's personnel file revealed that his Texas LVN nursing license had expired, and verification on the Texas Board of Nursing website confirmed the delinquent status. Despite this, LVN A continued to work for five days, providing care to residents without a valid license. During interviews, LVN A stated he was unaware of the expiration and believed his license was valid until 2025. The HR Coordinator, responsible for verifying licenses, also failed to notice the expired license and did not communicate this information to the Director of Nursing (DON) or other management members. The HR Coordinator admitted to not sending a license report to the DON or any other member of management and relied on the nurses to renew their licenses. The Administrator, who was new to the facility, and the DON both stated that they were not informed about the expired license until after surveyor intervention. The facility's policy required the HR Coordinator to monitor license expirations monthly, but this was not effectively implemented. As a result, LVN A worked a total of 47.15 hours with a delinquent license, which was only addressed after the surveyor's intervention.
Improper Transfer and Discharge of Resident
Penalty
Summary
The facility failed to ensure that residents were not transferred or discharged without adequate reason and proper documentation. Specifically, Resident #3 was transferred to another facility while his Medicaid application was still pending, and without waiting for the appeal process to be completed. The discharge notice given to Resident #3 did not include necessary information such as the contact details of the State Long-Term Care Ombudsman, the Texas Health and Human Services office, or instructions on how to file an appeal. This led to Resident #3 being transferred against his wishes and without proper communication regarding his rights to appeal the discharge decision. Resident #3 had a history of heart failure, type 2 diabetes mellitus, and generalized osteoarthritis. He was admitted to the facility after a fall at home, a hospital stay, and a wound that required therapy services. Despite completing therapy and having his wound healed, Resident #3 remained wheelchair-bound and unable to care for himself. He expressed frustration over the lack of communication regarding his Medicaid application and ultimately agreed to the transfer after months of not receiving any information. Interviews with facility staff revealed a lack of understanding and communication regarding the Medicaid application process and medical necessity determinations. The Financial Manager admitted to not reviewing the facility's discharge policy and not fully understanding medical necessity requirements. The MDS Coordinator determined that Resident #3 did not meet medical necessity based on his diagnoses and cognitive impairment score, but this decision was not communicated effectively to the resident or other staff members. The Social Worker also failed to discuss the discharge notice or appeal rights with Resident #3. The new facility that received Resident #3 was able to obtain Medicaid approval for him, highlighting inconsistencies in the original facility's handling of the situation.
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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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