South Dallas Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 3808 S Central Expwy, Dallas, Texas 75215
- CMS Provider Number
- 675440
- Inspections on file
- 45
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at South Dallas Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a clean, safe, and well-kept environment in several halls, common areas, and a resident room. Exit doors on multiple halls had accumulated dark dirt and leaves, and the dining room flooring near the kitchen and ice machine was torn. In one room, an A/C unit was loose and gapping from the wall with visible gunk and matted black dirt, a hole in the adjacent wall, and a toilet missing its tank cover. Staff interviews showed that while all staff were expected to report environmental and maintenance issues, housekeeping coverage was inconsistent, some areas were not being routinely cleaned, and needed repairs were not identified or reported in a timely manner.
Surveyors found unsanitary kitchen conditions, including an uncovered floor drain near the dishwashing area, a non-operational sink covered with a plastic bag from which a rodent was seen exiting, and about 30 gnats swarming over plates and old food on a tray rack. A large rat trap with a small food scooper was stored on the bottom rack of a food prep table. Dietary staff present during the rodent sighting declined to be interviewed. The DM reported a history of pest and rodent activity, frequent sink backups with standing water that contributed to gnat multiplication, and acknowledged that these conditions were unsanitary. Leadership staff, including the ADON, DON, MHS, and ADM, reported no known resident complaints or illnesses related to food or pests, but recognized that such infestations and conditions could make residents sick. Pest control records showed recent capture of multiple rats and mice in the kitchen and treatment for fruit flies and other insects, despite a facility sanitation policy requiring the kitchen to be kept clean and protected from pests.
The facility failed to maintain an effective pest control program, as evidenced by multiple resident and staff observations of rodents in resident rooms and hallways and surveyor observations of gnats and a rodent in the kitchen. An anonymous resident had video evidence of a rodent near his bed and reported seeing rodents on multiple occasions without reporting them, while another resident reported a rodent emerging from his closet. A CNA reported a hallway rodent and the use of glue traps, and the Business Office Manager reported a rodent entering the front office and moving down the hallway. Despite these events, the grievance log contained no pest-related entries, and several staff, including the ADON, SW, and DON, stated they had not observed rodents or insects or received resident reports, even as pest control contractor records documented repeated captures of mice and rats, treatment for fruit flies, and structural issues that could allow pest entry. The facility’s own pest control policy required an ongoing program to keep the building free of insects and rodents, but the documented rodent and insect activity in resident and kitchen areas showed that this program was not effectively implemented.
Surveyors found that one of two oxygen cylinders stored next to a crash cart behind a nurse’s station was not secured in a rack, contrary to NFPA 99 requirements that freestanding cylinders be properly chained or supported. An LVN acknowledged the tank was unsecured, stated she had just started her shift and had not noticed it, and confirmed it should always be secured because it was a hazard and could cause a fire. The DON reported she was unaware the tank was unsecured, indicated that night shift staff were responsible for checking crash carts and may have changed out the tank and failed to return it to the storage room, and stated her expectation that oxygen tanks be secured at all times, while also noting the facility lacked a policy on oxygen storage.
Four dietary staff members, including cooks and aides, were found to be working without valid Texas Food Handler's Licenses despite being employed for over 30 days. Interviews revealed staff were unaware of the certification requirement, and the dietary manager and administrator could not provide documentation of completed training as required by state regulations.
Surveyors found that the facility failed to maintain proper kitchen sanitation and maintenance, including non-functioning handwashing sinks, poor drainage in the dishwashing area, and evidence of pest activity. Staff confirmed that these issues had persisted for over a month, and observations showed that food storage and preparation areas were not kept clean as required by facility policy.
The facility did not maintain the kitchen range hood in working order for an extended period, resulting in a nonfunctional hood and smoky conditions during meal preparation. Staff interviews confirmed the hood had been out of service for at least one to four months, affecting all residents who received food from the kitchen.
The facility did not maintain an effective pest control program, resulting in the presence of gnats and rodent droppings in the kitchen. Staff reported repeated sightings of rats and mice, evidence of rodents eating food, and ongoing issues with gnats. Pest control services were provided twice monthly, but pest activity and droppings persisted, and cleaning responsibilities were unclear among staff.
A resident with severe cognitive impairment and multiple diagnoses was not included, nor was their representative invited, in care plan meetings. Facility staff confirmed that the responsible party was not contacted for participation, and documentation of their involvement was lacking, despite facility policy requiring such inclusion.
A resident with multiple chronic conditions fell while attempting an unassisted transfer, resulting in injury. Although nursing staff documented that the physician, hospice, and family were notified, the resident's family reported not being informed of the incident until the resident was sent to the hospital. Documentation did not confirm timely or successful family notification, contrary to facility policy.
A resident with multiple medical and cognitive conditions made an allegation of rough care and inappropriate conduct by a hospice aide. The facility's investigation was incomplete, lacking identification of the alleged perpetrator, notification to hospice, and required documentation, with the DON not informed until much later. Facility policy for incident investigation and reporting was not followed.
A resident with severe cognitive impairment and multiple comorbidities was not promptly referred for dental services after losing dentures. Facility staff failed to communicate and document the issue, resulting in the resident not being included on the dental provider's appointment list until the deficiency was identified. The resident continued on a regular diet without assessment for chewing or swallowing difficulties, contrary to facility policy.
Three residents with cognitive impairment and orders for wander guards did not have these interventions documented in their care plans. Despite physician orders and progress notes indicating the use of wander guards for exit-seeking or wandering behaviors, the care plans failed to reflect this service. Facility staff confirmed that care plans were not updated to include the required interventions.
Two residents with severe cognitive impairment and a history of exit-seeking were not provided with functioning wander guard devices as required by their care plans and physician orders. Despite staff documentation indicating regular checks, direct observation showed that the devices were not active and did not trigger the alarm system when tested. This failure to ensure proper operation of safety devices resulted in inadequate supervision and increased risk of incidents.
A resident with hemiplegia and cognitive impairment experienced a slip during a transfer from a shower chair, which staff failed to report as a fall or document. No pain or skin assessments were performed, resulting in an undiagnosed fracture for 11 days. After hospitalization, the facility did not arrange the required orthopedic follow-up, and there was no documentation of communication with hospice regarding the appointment, leading to a prolonged delay in specialist care.
A resident with left-sided paralysis and cognitive impairment was transferred from a shower chair to a wheelchair by a CNA and an LVN without the use of a gait belt and while still wet, contrary to facility protocol. The resident slipped during the transfer and later was found to have sustained a comminuted fracture to the left shoulder. The incident was not immediately reported or documented, and staff interviews confirmed that required safety measures were not followed.
A resident receiving hospice care, who had significant physical and cognitive impairments, did not have a designated staff member responsible for coordinating care and communication with the hospice agency. Instead, multiple staff members were involved inconsistently, and the hospice social worker was not notified of important care events. Facility policy required a specific team member to be assigned for this role, but this was not done, resulting in lapses in communication and care planning.
Multiple residents reported and were observed to have issues with roaches and mice in their rooms and hallways, with evidence of pest activity such as droppings and food damage. Staff interviews confirmed ongoing pest problems, and record review showed lapses in pest control service and documentation, despite facility policy requiring regular treatment and monitoring.
A resident with hemiplegia and dementia experienced a slip in the shower chair during transfer, resulting in a shoulder fracture. The incident was not documented or reported by staff at the time, and there was no evidence of timely pain or skin assessment. Hospice staff later identified the injury and notified facility staff, but the required report to the State Agency was not made within the mandated 2-hour window, in violation of facility policy and regulatory requirements.
The facility failed to provide adequate pharmaceutical services, resulting in deficiencies in medication administration and documentation for two residents. One resident did not receive pain medications as ordered upon admission, while another did not receive intravenous antibiotics timely. The facility's policies on medication administration and documentation were not followed, leading to incomplete MARs and missing pharmacy delivery receipts.
A resident's request to receive medications at a later time was not honored, despite his care plan allowing for decision-making in his treatment regime. The resident, with multiple health conditions, refused medications offered earlier than his preferred time, and staff did not return to administer them later. The LVN cited no risk for missing one dose, while the DON emphasized medication administration without addressing self-determination.
A resident with moderate cognitive impairment was found using a portable heater in their room due to a malfunctioning in-wall unit. The heater, provided by the facility, was used for two days without direct supervision, posing a fire risk. Staff were unaware of the heater's presence, and no fire watches were conducted. The facility failed to provide a policy on portable heaters, highlighting inadequate supervision and potential hazards.
A resident with diabetes did not receive daily fasting blood sugar checks as ordered by the physician on multiple occasions. The resident was aware of the missed checks but did not report them, assuming facility management was aware. Interviews with staff indicated the checks were the responsibility of the overnight nurse, but there was no documentation of refusal by the resident. The DON and Administrator were unaware of the issue until it was reported.
A facility failed to provide a safe and homelike environment, as seen in a resident's bathroom and a communal shower room. The resident's bathroom had visible plumbing and smeared tiles, while the shower room was unsanitary with foul odors, missing tiles, and a black substance around the shower. Despite complaints, the Maintenance Supervisor was unaware of these issues, and no maintenance requests were logged. The shower room, the only functional one, was used for storing dirty linen and trash, worsening the conditions.
The facility failed to ensure a sharps container in the Hall 300 shower room was monitored and emptied before becoming overfilled, leaving used razors unsecured. The shower room door was found open and unattended, posing a risk to residents. Staff interviews confirmed the door should have been locked and the container emptied when full, as per facility policy. The DON and ADM acknowledged the potential hazard, emphasizing the responsibility of nursing staff to manage sharps disposal.
The facility failed to provide adequate pharmaceutical services, as expired medications and supplies were found in the medication room. This included IV administration sets, IV insertion cannulas, and acetaminophen suppositories. The deficiency potentially affected a resident receiving IV medications and another prescribed the expired suppositories. Interviews revealed a lack of awareness and accountability regarding the expired supplies, and the facility's policy on medication storage was not followed.
The facility failed to maintain essential kitchen equipment, resulting in a non-functional handwashing sink and drainage issues with the dishwashing sink and dishwasher. These problems persisted for over a year, posing risks of unsanitary conditions and staff injury. Despite efforts by the new Administrator and Dietary Manager to address the issues, they remained unresolved due to delays in receiving necessary invoices for funding.
The facility's pest control program was ineffective, as evidenced by live flies and roaches in the only active shower room. Observations and interviews with residents and staff confirmed the presence of pests, with reports of roaches and flies in both the shower room and residents' rooms. The pest control log showed sporadic entries, and staff acknowledged the issue but lacked consistent documentation and response.
Two residents in the facility were observed without privacy covers on their catheter bags, compromising their dignity and privacy. Despite care plans and facility policies emphasizing the importance of maintaining resident dignity, staff interviews revealed a lack of awareness and communication regarding the absence of these covers. The residents, one with severe cognitive impairment and the other with chronic health conditions, were left exposed, with their catheter bags visible from doorways.
A resident with a seizure disorder had an abnormal Keppra level that was not promptly reported to the physician, as required by facility policy. The lab results were not flagged in the electronic medical record system, leading to the oversight. The DON and ADON acknowledged the lapse, and the physician expected all lab results to be reported, despite routine monitoring not being deemed necessary unless symptoms were present.
Two residents with cognitive impairments eloped from a facility due to inadequate supervision and access to door codes. One resident was arrested after leaving the facility, while the other suffered a stroke and was hospitalized. The facility's failure to monitor and restrict access contributed to these incidents.
Two residents with dementia eloped from a facility due to inadequate supervision and failure to follow protocols. One resident, with moderate cognitive impairment, left unnoticed and was arrested for obstructing a train. The second resident, wearing a wander guard, eloped and suffered a stroke. Staff failed to perform required checks and ensure wander guard functionality, leading to these incidents.
Two residents with cognitive impairments eloped from a facility due to inadequate supervision and assistance devices. One resident, with dementia, left the facility after obtaining a door code from another resident and was later arrested for impeding a train. Another resident, at high risk for wandering, left the facility multiple times despite wearing a wander guard, and was found at a transfer station after suffering a stroke. The facility failed to effectively monitor and manage these residents' exit-seeking behaviors.
Two residents in an LTC facility did not receive scheduled showers or bed baths, as required for their ADL care. One resident, cognitively intact, reported not receiving bed baths due to staff shortages, while another with moderate cognitive impairment had inadequate documentation of care. Staff interviews revealed a lack of awareness and scheduling issues in the electronic care system, leading to the deficiency.
A facility failed to protect a resident's medical information when an LVN left a computer displaying wound care details unlocked and unattended. The resident, who was cognitively intact and had multiple medical conditions, had their privacy compromised as two residents and a visitor passed by the nurse's station during this time. The LVN admitted to the oversight, which violated the facility's policy on resident privacy.
A resident in an LTC facility was found with a 0.9% sodium chloride syringe left on his bedside table, contrary to State and Federal laws requiring drugs and biologicals to be stored in locked compartments. The resident, who was cognitively intact, reported that nurses often left items in his room. LVN D, the assigned nurse, acknowledged it was her responsibility to remove such items but did not recall leaving the syringe. The facility's policy mandates secure storage of medications, highlighting a lapse in adherence to these guidelines.
A facility failed to maintain an effective pest control program, leading to a gnat infestation in a resident's room. The resident, who was nonverbal, confirmed the issue but could not specify to whom it was reported. The LVN and DOM were unaware of the problem, despite the facility's pest control company visiting monthly and no pest reports documented in the maintenance logs.
The facility failed to update the daily nurse staffing information on one of the reviewed days. Observations showed that the posting near the dining room was outdated, displaying the previous day's date. The DON was unaware of the lapse, attributing it to the ADON not providing the necessary staffing sheets for the current pay period. The ADMIN confirmed the oversight and noted that the ADON and receptionist were responsible for the updates.
Failure to Maintain Clean, Safe, and Well-Maintained Environment in Resident Areas and Common Spaces
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, sanitary, and well-kept environment in multiple areas, including resident rooms, exit doors, and common areas. Observations on the 100, 200, and 300 halls showed exit glass doors with an accumulation of dark black dirt and leaves. The flooring in the dining room next to the kitchen entrance and ice machine was damaged, with torn vinyl exposing underlying material. Staff interviews revealed that housekeeping was responsible for cleaning resident rooms, but a CNA reported not observing housekeepers cleaning the doors and floors at the end of every hall. The Maintenance/Housekeeping Supervisor (MHS) stated he had not observed the soiled condition of the doors and acknowledged ongoing problems maintaining housekeeping staff. In one resident room, surveyors observed an air conditioning unit that was loose and separated from the wall, creating gaps, with gunk and matted black, sticky, greasy dirt around the unit and a hole in the wall structure to the right of the unit near the closet. The same room’s toilet was missing its tank cover. The MHS stated that bathroom repairs were his responsibility and that structural issues such as gaps and holes in walls were contracted out when he was notified. He also initially suggested that residents sometimes removed toilet tank covers, but after being given the specific room number, he acknowledged that this particular resident was unable to remove the tank cover. The ADON and CNA confirmed that all staff were responsible for reporting environmental and maintenance needs and that failure to report could result in residents living in unsanitary conditions.
Unsanitary Kitchen Conditions with Rodent and Gnat Activity
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During an observation, surveyors noted an uncovered floor drain near the dishwashing area, which was left open after the Dietary Manager removed the cover while vacuuming standing water. In the dishwashing room, approximately 30 gnats were observed swarming over plates and old food on the tray rack. A large rat trap with a small food scooper was also observed stored on the bottom rack of a food preparation table in the kitchen, even though dining room staff were not actively preparing food at that time. Surveyors further observed a rodent exiting a plastic bag that had been placed over a non-operational kitchen sink near the prep area. The Dietary Manager later explained that the sink frequently stopped up, causing standing water, and that a plastic trash bag was used to cover the sink to prevent bugs, insects, and rodents from entering the kitchen. He acknowledged that the facility had a history of pest and rodent observations and that when the sink overflowed, gnats tended to multiply. Dietary staff present during the rodent observation declined to be interviewed about insect and rodent concerns in the kitchen. Interviews with the ADON, DON, Maintenance/Housekeeping Supervisor, and Administrator revealed that they were not aware of resident complaints or illnesses related to food, insects, or rodents, although they recognized that rodents, insects, and unsanitary conditions could make residents sick. Record review of a recent pest control visit documented the capture of multiple rats and mice in the kitchen and treatment for fruit flies and various crawling insects. The facility’s own sanitation policy required that kitchens and dining areas be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects, and that equipment and food-contact surfaces be maintained in good repair and cleanliness, which was not met under the observed conditions.
Failure to Maintain Effective Pest Control in Resident and Kitchen Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program to prevent and address rodents and insects throughout the building, including resident rooms and the kitchen. An anonymous resident had a video dated 02/11/2026 showing a rodent on the floor near his bed on his side of the room; he reported that he did not notify staff at the time and had seen rodents in his area on two other occasions. Another resident reported seeing a rodent coming out of his closet at night on 04/07/2026. A CNA reported observing a rodent in a hallway on 04/07/2026 and stated that glue traps were placed in areas where rodents were observed and that a rodent had been removed from a glue trap that morning. Despite these resident and staff observations, the grievance log from 02/01/2026 to 04/07/2026 contained no entries related to rodents, pests, or insects. Surveyors observed gnats and a rodent in the kitchen during inspection on 04/08/2026, including a small rodent exiting a kitchen sink that had been covered with a clear plastic trash bag. The Dietary Manager acknowledged that the plastic trash bag was being used to cover a non-working sink in an attempt to prevent bugs, insects, and rodents from entering the kitchen and stated he did not have an answer for treatment of the gnats. The Business Office Manager reported personally seeing a rodent enter the front reception office and move down the hallway and described the issue as occurring on and off. The facility’s pest sighting log documented a rat observed in the front office on 04/06/2026, and the maintenance log also reflected a rodent observation in the front office on that date. Multiple staff members, including the ADON, SW, and DON, stated they had not personally observed rodents or insects and had not received resident reports of such issues, while also acknowledging that rodents and infestations could lead to resident illnesses due to unsanitary conditions and that all staff were responsible for reporting environmental concerns. The Administrator stated that the Maintenance/Housekeeping Supervisor was responsible for pest control and that pest control technicians were visiting daily, with glue traps checked and rodents removed. Pest control contractor records from February and March 2026 documented repeated captures of mice and rats in the kitchen and treatment for fruit flies and other insects, as well as observations of exterior structural issues such as moisture damage, holes in exterior walls, cracks in mortar and bricks, and gaps and rotten structures. The facility’s pest control policy, dated May 2008, stated that the building was to be kept free of insects and rodents through an ongoing pest control program, with proper materials and procedures, daily removal of garbage and trash, and maintenance assistance as needed, but the documented observations and contractor reports showed ongoing rodent and insect activity in resident and food service areas during the review period. Pest control service documentation further showed that during multiple visits, the pest control contractor captured numerous rodents and treated for fruit flies and other crawling insects in the kitchen, common areas, and resident rooms. One service description for commercial rodent premium coverage outlined sealing potential rodent entry points, mass trapping, additional exterior bait stations, and ongoing inspections to identify and repair new entry points, indicating that significant rodent activity had been identified and required extensive intervention. Despite these findings and the facility’s written policy requiring an effective pest control program, the presence of rodents and gnats in resident care and food preparation areas, combined with the lack of corresponding grievances and inconsistent staff awareness of resident reports, demonstrated that the facility did not effectively implement or maintain its pest control program during the period reviewed.
Unsecured Oxygen Cylinder at Nurse’s Station
Penalty
Summary
The facility failed to provide a safe environment by not securely storing one of two oxygen cylinders observed at a nurse’s station. During observation, two oxygen cylinders were seen next to the crash cart behind the nurse’s station, with one cylinder properly secured in a rack and the other left unsecured. Later observation and interview with an LVN confirmed the oxygen tank was not secured; the LVN stated she had just started her shift, had not noticed the unsecured tank, and acknowledged it should always be secured in a rack because it was a hazard and could cause a fire. In a subsequent interview, the DON stated she was not aware the tank was unsecured, explained that night shift staff had been tasked with checking crash carts and had probably changed out the tank and forgotten to return it to the storage room, and stated her expectation that tanks be secured at all times because they could be knocked over. The DON also reported that the facility did not have a policy on oxygen storage, despite NFPA 99, 2012 Edition, Section 11.6.2.3 requiring freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart. No specific residents were identified as directly involved at the time of the observation, and no resident medical histories or conditions were described in relation to this deficiency.
Failure to Ensure Dietary Staff Hold Required Food Handler Certification
Penalty
Summary
The facility failed to employ sufficient dietary staff with the appropriate competencies and skill sets, as evidenced by four out of five reviewed dietary staff members lacking a valid Texas Food Handler's License. Record reviews confirmed that Cook A, three other dietary staff, and a dietary aide had all been employed for more than 30 days without obtaining the required certification. Multiple interviews with these staff members revealed they were unaware of the requirement or the timeframe for obtaining the food handler's license. The new dietary manager, hired nine days prior to the survey, also confirmed she could not locate any current food handler certificates for these staff members and acknowledged her responsibility for ensuring staff training and certification. Further interviews with the Administrator and dietary manager indicated a lack of oversight and understanding regarding the process and timeline for obtaining food handler certification. Despite requests, the facility was unable to provide documentation of food handler licenses for the kitchen staff prior to the survey exit. Review of Texas Department of State Health Services regulations confirmed that all food employees, except for the certified food protection manager, must complete accredited food handler training within 30 days of employment, and the facility must maintain certificates on the premises.
Deficient Kitchen Sanitation and Maintenance
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food service safety and sanitation. Both handwashing sinks were not in proper working order: one leaked from a pipe beneath the sink, requiring a basin to catch water, while the other was non-functioning with no running water from the faucet. The dishwashing room also had drainage issues, with water not draining properly and staff using a wet vacuum to remove water from the floor. Pest droppings were found in all three sections of a nonfunctioning dishwashing sink and on the floor beneath another nonfunctioning sink, and several gnats were observed in the nonfunctioning handwashing sink. Interviews with staff confirmed that the plumbing and drainage issues had persisted for at least a month and a half. Staff described using a wet vacuum to manage water overflow due to the drainage problem. The dietary manager and administrator were aware of the plumbing and pest issues, with the dietary manager stating that plumbing was a top priority and the administrator confirming knowledge of the problems prior to the survey. The facility's Nutrition Services Policy & Procedures required food storage areas to be kept clean at all times, but observations indicated this standard was not met.
Failure to Maintain Kitchen Range Hood in Safe Working Order
Penalty
Summary
The facility failed to maintain the kitchen range hood in good repair, resulting in the equipment being nonfunctional for an extended period. Multiple staff interviews confirmed that the range hood had not worked for at least one to four months, during which time the kitchen would become smoky when cooking on high. Staff reported that all residents received food prepared in this kitchen. The Dietary Manager (DM) and other staff were aware of the issue, and there were occasions when the kitchen was full of smoke due to the inability to use the range hood. The Administrator acknowledged awareness of the nonfunctional range hood prior to the survey and stated that a work order and quotes for repair had been obtained. The maintenance service policy required that equipment be maintained in a safe and operable manner at all times, but the range hood remained out of service until after the deficiency was identified. The facility census at the time was 68 residents, all of whom relied on the kitchen for meals.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and rodent droppings in the kitchen over multiple days. Observations included pest droppings in all three sections of a nonfunctioning dishwashing sink, another nonfunctioning sink, and on the floor beneath that sink. Five gnats were observed in a nonfunctioning hand washing sink near the dishwasher. Multiple staff interviews confirmed repeated sightings of rats and mice in the kitchen and pantry, with one staff member reporting that bread had to be stored in the freezer due to rodents eating through packaging. Staff also reported that rodents had been caught in traps and that gnats were present throughout the kitchen. The Maintenance Director stated that the rodent issue began after concrete was broken up on the back patio and had been addressed with sticky bait, but he was unaware of ongoing sightings in the kitchen. Pest control services were documented as occurring twice per month, with logs indicating recent captures of mice and fruit flies. The Administrator acknowledged the presence of pest droppings and stated that kitchen cleaning was the responsibility of the dietary manager, but was unsure when the droppings were last cleaned. The facility's pest control policy emphasized frequent treatment and monitoring, but the observed conditions and staff reports indicated that the kitchen was not being maintained free of pests.
Failure to Include Resident Representative in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was invited to participate in the development and implementation of the resident's person-centered care plan. Record reviews and interviews revealed that the resident, who had severe cognitive impairment as indicated by a BIMS score of 3 and diagnoses including Alzheimer's disease, heart failure, hypertension, and a psychotic disorder, was not able to respond to questions and relied on a responsible party for decision-making. Despite this, there was no evidence that the responsible party was invited to or included in care plan meetings. Interviews with facility staff, including the social worker (SW), MDS coordinator, and administrator, confirmed that the SW was responsible for coordinating care plan meetings and inviting responsible parties or family members. However, the SW admitted to not having coordinated a care plan meeting for the resident in question during her tenure. The responsible party also reported never being invited to a care plan meeting, despite being contacted for medical consents and expressing a desire to be included. The MDS coordinator could not recall if the responsible party was invited to the most recent care plan meeting and was unable to provide sign-in sheets or documentation showing their participation. Review of the resident's care conference assessments showed attendance by facility staff but no indication that the responsible party or family attended. Additionally, the facility's policies required resident and/or representative participation in care planning and outlined procedures for notifying them in advance, but these were not followed in this case. Documentation for some care plan meetings was missing, further indicating a lack of compliance with established procedures.
Failure to Notify Family of Resident Injury After Fall
Penalty
Summary
The facility failed to notify a resident's representative following an incident that resulted in injury. A male resident with multiple diagnoses, including type 2 diabetes with foot ulcer, atherosclerotic heart disease, congestive heart failure, and stage 3 chronic kidney disease, experienced a fall while attempting to transfer from his bed to a wheelchair without assistance, despite requiring a two-person assist and a Hoyer lift for transfers. The resident was later observed with swelling to his face and right arm, and was subsequently sent to the hospital after physician notification. Interviews with nursing staff revealed inconsistencies in the notification process. One nurse stated she notified the physician, hospice, and family members after the fall, while another nurse relied on previous charting that indicated family notification had occurred. However, the resident's family member reported not being informed of the fall until the resident was being sent to the hospital, and documentation did not clearly indicate whether a message was left or if follow-up attempts were made after an initial unsuccessful call. Record reviews showed that progress notes and incident reports documented that the physician, hospice, and family were notified, but there was no conclusive evidence that the family was actually reached or informed in a timely manner. The facility's policies required immediate notification of family and documentation of such notifications following incidents or changes in condition, but these procedures were not consistently followed in this case.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident. Specifically, a resident with multiple diagnoses, including dementia, schizoaffective disorder, and cognitive communication deficit, made an allegation that a hospice aide was rough during perineal care and did not stop when requested. Additionally, the resident alleged inappropriate sexual contact and racial slurs by a hospice aide. The investigation report completed by the previous administrator did not identify the alleged perpetrator, lacked documentation that hospice was notified, did not include safe surveys, and failed to provide evidence of abuse and neglect in-services being conducted. Interviews revealed that the hospice Director of Nursing was not notified of the allegation until months later, and the current administrator, who was not involved in the original investigation, could not locate further information or documentation regarding the incident. Facility policy required thorough documentation of incidents, including witness accounts, physician notification, and corrective actions, but these elements were missing from the investigation. The resident later stated they did not recall the alleged abuse, but the lack of a comprehensive investigation and documentation was evident.
Failure to Timely Refer Resident for Dental Services After Loss of Dentures
Penalty
Summary
The facility failed to assist a resident in obtaining routine and emergency dental care in a timely manner. The resident, an elderly male with Alzheimer's disease, chronic obstructive pulmonary disease, and a history of subdural hemorrhage, was admitted to the facility with his own teeth intact according to initial assessments and care plans. However, subsequent observations and interviews revealed that the resident had no upper or lower teeth and could not recall what happened to his dentures or missing teeth. Despite this, there was no documentation or prompt referral for dental services when the dentures were reported missing. Interviews with facility staff indicated a lack of communication and unclear responsibility regarding the referral process for dental care. The Assistant Director of Nursing (ADON) stated she was not informed about the missing dentures and believed it was the responsibility of the Social Worker (SW) to submit referrals. The SW reported receiving a verbal complaint from the resident's family about the missing dentures but could not provide documentation or a specific date for when a referral was made. The resident was not initially included on the list for upcoming dental appointments, and only after further inquiry was a referral form completed and the resident added to the list. Further interviews with the Director of Rehabilitation, Dietitian, and Administrator confirmed that there was no prior notification or assessment regarding the resident's missing dentures or need for a diet change. The resident continued on a regular diet without documented chewing or swallowing difficulties, and staff were unaware of the dental issue until it was brought to their attention during the survey. Facility policy required prompt referral and documentation for such issues, which was not followed in this case.
Care Plans Lacked Documentation of Wander Guard Interventions
Penalty
Summary
The facility failed to ensure that the care plans for three out of four residents included documentation of services provided, specifically the use of wander guards. For one resident with severe cognitive impairment and a history of exit-seeking behavior, the care plan did not document the presence of a wander guard, despite physician orders and progress notes indicating its use. This resident had diagnoses including unspecified dementia, psychotic and mood disturbances, anxiety, hypertension, hypothyroidism, edema, and psychotic disorders with hallucinations and delusions due to physiological conditions. The resident's progress notes reflected active exit-seeking behavior, and orders were in place for a wander guard to be checked every 10 hours, but this intervention was not reflected in the care plan. Another resident, also with severe cognitive impairment and daily wandering behavior, had similar omissions. This resident's diagnoses included unspecified dementia, psychotic and mood disturbances, anxiety, sequelae of cerebral infarction, neuroleptic-induced Parkinsonism, chronic kidney disease stage 4, hypertension, anemia, cognitive communication deficit, difficulty in walking, and schizoaffective disorder. Despite daily wandering and an order for a wander guard, the care plan did not document this intervention. Progress notes indicated active exit-seeking behavior, but the care plan failed to reflect the use of the wander guard as an intervention. A third resident, with moderate cognitive impairment and no documented wandering behavior, also had an order for a wander guard, but the care plan did not include this intervention. Diagnoses for this resident included unspecified dementia, psychotic and mood disturbances, anxiety, hypothyroidism, difficulty in walking, generalized muscle weakness, and unspecified pain. The care plan lacked documentation of the wander guard, even though orders were in place for its use. Interviews with facility staff confirmed that the care plans were not updated to reflect the use of wander guards for these residents.
Failure to Ensure Functioning Wander Guard Devices for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that two residents with severe cognitive impairment received adequate supervision and functioning assistance devices to prevent incidents related to wandering and potential elopement. Both residents had diagnoses including unspecified dementia, psychotic disturbances, mood disturbances, and anxiety, with one also experiencing neuroleptic-induced Parkinsonism and chronic kidney disease. Documentation showed that both residents had orders for wander guard devices to be present and functioning on their lower extremities, with checks required every shift and specific instructions to test the devices at the front door to ensure alarms would sound. Despite these orders, observations revealed that neither resident's wander guard device was functioning properly at the time of survey. When tested at the front door, the devices did not activate the alarm, although the door alarm itself was operational. Staff interviews confirmed that checks for placement and functioning of the wander guards were documented as completed every shift, but the devices were not active during the survey. The ADON and maintenance staff stated that the system was checked regularly, and maintenance logs indicated that the system had passed recent checks. However, the handheld device used to activate or deactivate the wander guards was found to be inactive during the survey. Further review of records and interviews indicated that the facility had experienced previous issues with the wander guard system, including a recent repair to the front door alarm system. Despite staff and administrative claims that the system was functioning and that no residents had eloped, the direct observation of non-functioning wander guards for two residents with a history of exit-seeking behavior constituted a failure to provide adequate supervision and accident hazard prevention as required.
Failure to Report Fall, Assess Pain, and Arrange Follow-Up Care After Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to provide timely pain assessments and follow-up care for a resident with significant medical needs, including hemiplegia, vascular dementia, and aphasia. The resident experienced a slip during a transfer from a shower chair to a wheelchair, which was not reported as a fall by the staff involved. There was no documentation of the incident, pain, or skin assessments in the resident's records for the relevant period. The incident was only brought to the facility's attention after the resident and family reported ongoing pain, leading to a delayed diagnosis of a comminuted fracture in the left humeral bone, which went undetected for 11 days. The staff involved in the transfer did not use a gait belt and did not report the slip or any potential injury, as they believed the resident had not fallen and showed no immediate signs of pain or injury. The lack of reporting meant that the incident was not entered into the facility's accident log, and no immediate medical evaluation or x-ray was performed. The resident continued to experience pain, which was eventually communicated to hospice staff, who then notified the facility nurse and ordered pain medication. However, the underlying injury remained undiagnosed until the family intervened and requested further assessment. Additionally, after the resident was hospitalized and discharged with an order for an orthopedic follow-up, the facility failed to arrange the required appointment. There was no documentation that the hospice agency had been contacted regarding the follow-up, and the appointment was not made for several months. Interviews with facility staff revealed confusion over responsibilities for arranging such appointments, particularly in the absence of the social worker, resulting in a prolonged lack of necessary specialist care for the resident.
Failure to Use Gait Belt and Dry Resident During Transfer Results in Serious Injury
Penalty
Summary
A deficiency occurred when facility staff failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision and assistive devices during a transfer. Specifically, a male resident with left-sided hemiplegia, vascular dementia, and aphasia required substantial assistance for transfers and was dependent on staff for mobility and toileting. During a transfer from a shower chair to a wheelchair, staff did not use a gait belt as required by facility protocol, and the resident was not dried off prior to the transfer, resulting in the resident slipping and sustaining a comminuted fracture to the left humeral neck and glenoid bone. The incident was not immediately reported or documented in the facility's records. The resident did not report the incident until several days later, and there was no evidence in the facility's incident log or electronic health record of a fall, near fall, or injury during the relevant period. Staff involved in the transfer stated that the resident began to slip but was caught before falling, and no pain or injury was reported at the time. However, subsequent medical evaluation revealed significant fractures, and the resident required additional pain management and orthopedic consultation. Interviews with staff and review of facility policy confirmed that the use of a gait belt and ensuring the resident was dry before transfer were required safety measures that were not followed. The facility's policy also required ongoing assessment of residents' transfer needs and proper documentation, which was not evident in this case. The failure to adhere to established protocols and to document and report the incident led to the identification of an Immediate Jeopardy situation.
Failure to Designate Staff for Hospice Communication and Coordination
Penalty
Summary
The facility failed to designate a specific interdisciplinary team member responsible for collaborating with hospice representatives and coordinating the participation of LTC facility staff in the hospice care planning process for residents receiving hospice services. Instead, communication with hospice agencies was handled inconsistently, with various staff members such as nurses, the DON, the Administrator, and the Social Worker all potentially communicating with hospice, but without a clear assignment of responsibility. This lack of a designated point of contact was confirmed in interviews with the Administrator and DON, who both stated that no single person was assigned to communicate with hospice agencies. A resident with a history of hemiplegia, vascular dementia, and aphasia was admitted to the facility and later placed on hospice care. The resident required significant assistance with activities of daily living and had moderate cognitive impairment. Record reviews showed that the resident was admitted to hospice services, but there was no evidence that a specific staff member was coordinating care or communication with the hospice agency as required by facility policy. Further, the hospice social worker reported not being notified by the facility about the resident's follow-up appointments or receiving discharge paperwork after a hospital visit. The facility's policy required a designated team member to coordinate care and communication with hospice, but the policy form was left blank regarding the responsible individual's name and title. This failure to assign and document a responsible staff member led to gaps in communication and coordination of care for the resident receiving hospice services.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches and rodents in multiple resident rooms and a main hallway. Observations and interviews revealed that several residents saw roaches in their rooms and hallways, with some reporting the issue had been ongoing for months. One resident reported seeing mice in his room, with small black pellets observed under his air conditioning unit. Another resident reported mice chewing through his food, with similar pellets found behind his refrigerator and in his closet. Residents stated they had informed staff about these pest issues. The Maintenance Supervisor confirmed there had been a significant roach problem previously due to non-payment to the pest control company, resulting in missed treatments. He also acknowledged an ongoing mouse problem and recent placement of traps. Review of pest management records showed sporadic documentation of pest sightings and a lack of receipts or evidence of pest control service visits for several months. The facility's pest control policy required frequent and periodic treatments, monitoring, and prompt reporting, but these measures were not effectively implemented as evidenced by the continued presence of pests.
Failure to Timely Report Alleged Neglect and Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, as required by regulation. Specifically, an incident involving a resident with left-sided hemiplegia, vascular dementia, and aphasia was not reported to the State Agency within the mandated timeframe. The resident, who required substantial assistance for activities of daily living, experienced a slip in the shower chair while being transferred, which was not documented or reported at the time of occurrence. The incident was initially not recognized or documented by facility staff, and there was no evidence of a fall, skin, or pain assessment in the resident's records for the relevant dates. The resident later reported pain and a fall to hospice staff, who then notified the facility nurse and ordered pain medication. Despite this, the facility's incident and accident log did not reflect any record of the event, and the required reporting procedures were not followed. Interviews with staff revealed confusion and assumptions regarding who was responsible for reporting the incident, leading to a delay in notification to the Director of Nursing and the Administrator. The facility's policy required prompt investigation and reporting of all accidents or incidents, with documentation to be submitted to the Director of Nursing within 24 hours. However, in this case, the policy was not followed, and the incident was not reported to the appropriate authorities within the required 2-hour window. This lapse in procedure was confirmed through interviews and record reviews, which showed a lack of timely communication and documentation regarding the resident's fall and subsequent injury.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, resulting in deficiencies in medication administration and documentation. For one resident, the facility did not administer pain medications as ordered upon admission, despite the resident's request for pain relief. The resident, who had diagnoses including sepsis, polyneuropathy, and paraplegia, did not receive oxycodone until more than 24 hours after admission. The facility also failed to administer and document scheduled doses of gabapentin and trazodone for this resident, leading to a delay in pain management and insomnia treatment. Another resident, admitted with conditions such as a multidrug-resistant organism and septicemia, did not receive intravenous antibiotics as ordered. The facility failed to acquire and administer the antibiotics timely, and there were gaps in the medication administration record (MAR) for several medications. The resident's family reported that the facility did not provide medications for a day and a half after admission, and the resident eventually chose to go to the hospital to receive the necessary antibiotics. The facility's documentation and communication with the pharmacy were inadequate, contributing to the delay in medication delivery. The facility's policies on medication administration and documentation were not followed, resulting in incomplete MARs and missing pharmacy delivery receipts. The Director of Nursing (DON) acknowledged the delays in medication delivery and the lack of documentation for some medications. The facility's failure to ensure timely and accurate medication administration placed residents at risk of inadequate disease management and uncontrolled pain.
Failure to Honor Resident's Medication Timing Preference
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating his request to receive medications at a later time. The resident, who had diagnoses including sepsis, polyneuropathy, muscle spasm, and paraplegia, expressed his preference to receive his medications later in the evening, as he was accustomed to from his previous hospital stay. On the evening in question, the resident refused his medications when they were offered earlier than his preferred time, leading to a situation where his choice was not respected. The resident's care plan indicated that he was resistive to care and should be allowed to make decisions about his treatment regime. Despite this, the staff did not return to administer the medication at the time requested by the resident. The LVN involved acknowledged the resident's refusal and did not attempt to administer the medication later, citing no risk to the resident for missing one dose. The DON confirmed that medications should be administered as ordered but did not address the importance of respecting the resident's self-determination in care decisions.
Inadequate Supervision and Hazardous Equipment Use in Resident's Room
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accident hazards for a resident who was using a portable heater in their room. The resident, who had moderate cognitive impairment and required assistance for transfers and personal hygiene, was found with a portable heater operating within close proximity to their bed and privacy curtain. The heater was provided by the facility due to a malfunctioning in-wall heating unit, and the resident had been using it for two days without direct supervision. Interviews with staff revealed a lack of awareness and monitoring regarding the use of portable heaters in the facility. The Maintenance Supervisor acknowledged the potential fire risk posed by the heater and stated that it had been removed after replacing the in-wall unit. However, no fire watches were conducted during the heater's use, and the facility did not provide a policy on portable heaters when requested. This oversight placed residents at risk for accidents or injuries due to inadequate supervision and potential fire hazards.
Failure to Follow Physician Orders for Blood Sugar Checks
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not follow physician orders for daily fasting blood sugar checks for a resident on multiple occasions. The resident, who was cognitively intact and had a history of diabetes mellitus with neuropathy, was aware that his blood sugar should be checked every morning but reported that the facility nurses did not perform these checks consistently. The resident did not report the missed checks to facility management, assuming they were already aware of the issue. Interviews with facility staff revealed that the responsibility for the blood sugar checks was assigned to the overnight nurse, but there was no documentation indicating that the resident refused the checks. The Director of Nursing (DON) and the Administrator were not aware of the missed checks until the issue was brought to their attention. The facility's medication administration record confirmed the missed checks, and there was no related policy provided by the DON or Administrator before the exit.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the conditions in Resident #8's bathroom and the shower room used by multiple residents. Resident #8, who has a history of major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and mild cognitive impairment, reported that her bathroom wall had been in disrepair since her admission, with visible plumbing and smeared tiles. Despite her complaint to the Maintenance Supervisor, no action was taken, and the issue was not logged in the maintenance records for several months. Additionally, the shower room on the 300 hall was found to be unsanitary and in poor condition, with a strong foul odor, missing tiles, and a black substance around the shower edges. Residents reported the room as "nasty" and infested with roaches, with dirty briefs and overflowing trash contributing to the unsanitary conditions. The Maintenance Supervisor was unaware of these issues, as no maintenance requests had been submitted, and the room's condition was not documented in the maintenance logs. Interviews with staff revealed that the shower room was the only functional one available, and it was used to store dirty linen and trash, exacerbating the odor and cleanliness issues. The Assistant Director of Nursing (ADON) acknowledged the problem but had not yet found an alternative storage solution. The facility's policy on maintaining a homelike environment was not adhered to, as evidenced by the lack of cleanliness and order in the resident's bathroom and the communal shower room.
Failure to Secure Sharps Container and Shower Room
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that a sharps container in the shower room on Hall 300 was properly monitored and emptied before becoming overfilled. Observations revealed that the sharps container was overflowing past the fill line, with five used disposable razors left unsecured on top. The shower room door was found open and unattended, posing a risk of injury to residents who might access the room unsupervised. Interviews with staff, including a medication aide and a licensed vocational nurse, confirmed that the door should have been locked and the sharps container emptied when full. Both staff members acknowledged the potential hazard posed by the unsecured razors. The Director of Nursing (DON) and the Administrator (ADM) confirmed that the facility's policy required used razors to be disposed of in sharps containers and that these containers should be emptied when reaching the fill line. The DON stated that all nursing staff were responsible for ensuring the containers were emptied, and keys to the containers were accessible to staff. Despite these protocols, the failure to secure the shower room and properly manage the sharps container created a potential risk for residents, particularly those with dementia, who could have accessed the razors and harmed themselves.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by the presence of expired medications and supplies in the medication room. During an observation, it was noted that the medication room contained an almost full box of IV administration sets with an expiration date of June 5, 2024, ten IV insertion cannulas with an expiration date of February 28, 2024, and six acetaminophen 650mg suppositories with a use-by date of December 11, 2023. These expired items were not removed or disposed of according to the facility's policy, which states that discontinued, outdated, or deteriorated drugs should be returned to the dispensing pharmacy or destroyed. The deficiency potentially affected two residents: one receiving IV medications and another prescribed the expired acetaminophen suppositories. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed a lack of awareness and accountability regarding the expired supplies. The ADON mentioned that the medication room was checked monthly for expired items, but the expired supplies were still present. The DON acknowledged the risk posed by the expired IV supplies but did not specify who was responsible for monitoring expiration dates. The facility's policy on medication storage was not adhered to, leading to the presence of expired medications and supplies in the medication room.
Deficiencies in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff, as evidenced by issues with essential kitchen equipment. Specifically, the handwashing sink in the kitchen was non-functional, with no running water available from the faucet. Additionally, the dishwashing sink and dishwasher were unable to drain properly, leading to water accumulation. These deficiencies were observed during a survey of the kitchen, where a wet vacuum was noted to be used to manage the water overflow, indicating a persistent drainage problem. Interviews with the Dietary Manager and the Administrator revealed that these issues had been ongoing for at least a year. The Dietary Manager acknowledged the risk of injury to staff and the potential for an unsanitary kitchen environment due to the drainage problems. The Administrator, who took over the facility in June 2024, confirmed that the issues were known during the turnover with the previous administrator. Despite attempts to resolve the problems, including hiring a new dietary manager and contacting plumbers, the issues remained unresolved due to delays in receiving necessary invoices for funding approval.
Ineffective Pest Control Program in Shower Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live small flies and roaches in the only active shower room. Observations revealed a small fly on the door frame and multiple live roaches and flies in the shower room. Interviews with staff and residents confirmed the presence of pests, with reports of roaches and flies in both the shower room and residents' personal rooms. The pest control log indicated sightings of roaches on several occasions, but entries were sparse and did not reflect the ongoing issue. The contracted pest control company had visited the facility and treated for various pests, but the problem persisted. Staff interviews revealed a lack of consistent documentation of pest sightings in the pest control log, which was supposed to guide pest control efforts. The Maintenance Supervisor and other staff acknowledged the issue and the potential impact on residents' quality of life, but there was no evidence of a comprehensive or effective response to the pest problem.
Failure to Maintain Resident Dignity Due to Lack of Privacy Covers
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents by not providing privacy covers for their catheter bags. Observations revealed that the catheter bags of these residents were left uncovered and visible from the doorways, which could lead to embarrassment and low self-esteem for the residents. This issue was identified during multiple observations over two days, where the catheter bags were consistently found without privacy covers. Resident #49, a male with a history of cerebral infarction, hemiplegia, and severe cognitive impairment, required extensive assistance with daily activities and had an indwelling catheter. Similarly, Resident #57, a male with chronic health conditions and cognitive intactness, was completely dependent on assistance and used an external catheter. Both residents' care plans included interventions to maintain their dignity and prevent catheter-related issues, yet the lack of privacy covers was not addressed. Interviews with staff, including CNAs and the DON, highlighted a lack of awareness and communication regarding the absence of privacy covers. Staff acknowledged the importance of privacy covers for maintaining resident dignity but were unaware of any shortages or missing covers. The facility's policy emphasized the importance of promoting resident dignity and privacy, yet this was not upheld in practice, as evidenced by the observations and staff interviews.
Failure to Notify Physician of Abnormal Keppra Levels
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal laboratory results for a resident taking Keppra, an antiseizure medication. The resident, who had a seizure disorder and moderate cognitive impairment, had a Keppra level that was out of the normal range on a specific date. Despite the facility's policy requiring prompt notification of high or toxic medication levels, the abnormal result was not communicated to the physician. Interviews revealed that the lab results were not flagged in the electronic medical record system, leading to the oversight. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the lapse, noting that the results were available in the electronic medical records and should have been communicated during shift reports. The facility's policy stated that nurses should notify physicians of high or toxic levels promptly, but this was not done. The physician indicated that routine monitoring of Keppra levels was not necessary unless the resident showed symptoms, but expected all lab results to be reported. The failure to notify the physician could result in the physician not being fully aware of the resident's clinical condition.
Facility Fails to Prevent Resident Elopement Leading to Arrest and Hospitalization
Penalty
Summary
The facility failed to prevent the elopement of two residents, leading to significant incidents. The first resident, diagnosed with dementia and other conditions, was able to leave the facility without supervision due to inadequate monitoring and access to the door code. Despite being assessed as a low risk for wandering, the resident left the facility and was later arrested for obstructing a train. The facility's failure to properly supervise and restrict access to the door code contributed to this incident. The second resident, also with cognitive impairments, repeatedly attempted to leave the facility and was eventually successful. Despite wearing a wander guard, the resident managed to exit the facility and was found at a transfer station, having suffered a stroke. The facility's inability to effectively monitor and prevent the resident's elopement, despite clear signs of exit-seeking behavior, resulted in the resident's hospitalization. Both incidents highlight the facility's failure to ensure adequate supervision and security measures for residents at risk of elopement. The lack of proper monitoring, failure to restrict access to door codes, and insufficient response to residents' exit-seeking behaviors were significant factors leading to these deficiencies.
Failure to Prevent Resident Elopement and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures to prevent neglect, resulting in two residents eloping from the facility. The first resident, diagnosed with dementia and moderate cognitive impairment, was able to leave the facility without supervision. Despite being assessed as a low risk for wandering, the resident had access to the door code, which was shared by another resident. The resident left the facility unnoticed and was later arrested for obstructing a train. The facility's failure to conduct proper monitoring and ensure the resident's safety led to this incident. The second resident, also diagnosed with dementia and wearing a wander guard, repeatedly attempted to leave the facility. Despite being on 15-minute checks, the resident managed to elope and was found at a transfer station, having suffered a stroke. The facility's staff did not perform the required checks, and the wander guard system failed to prevent the resident from leaving. The resident's elopement and subsequent medical emergency highlight the facility's inability to adequately supervise and protect residents at risk of wandering. Interviews with staff and record reviews revealed that the facility did not adhere to its protocols for monitoring residents at risk of elopement. Staff failed to conduct regular checks and did not ensure that wander guard devices were functioning correctly. The facility's lack of effective supervision and failure to follow established procedures contributed to the residents' elopements and the resulting adverse outcomes.
Inadequate Supervision Leads to Resident Elopements
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents, leading to incidents of elopement. The first resident, who had moderate cognitive impairment due to dementia, was able to leave the facility without being noticed. This resident had access to the door code, which was given by another resident, and left the facility to smoke off property. The resident was later found 3.5 miles away and was arrested for impeding a train. Despite having a low risk for wandering, the resident's elopement risk assessments did not account for the possibility of obtaining the door code from another resident. The second resident, who was at high risk for wandering due to dementia, was wearing a wander guard device. However, the resident managed to leave the facility multiple times, including an incident where the resident was found lying on the ground at a transfer station after suffering a stroke. The resident's care plan included interventions to distract from wandering, but these measures were insufficient to prevent the resident from leaving the facility. The resident's behavior of packing belongings and expressing a desire to leave was noted, but the facility's interventions failed to effectively manage these behaviors. Both incidents highlight a lack of effective monitoring and supervision, as well as inadequate use of assistance devices like wander guards. The facility's failure to ensure that wander guards were functioning properly and to prevent residents from obtaining door codes contributed to these elopements. The facility's staff did not adequately monitor the residents' movements, and there was a lack of timely response to the residents' exit-seeking behaviors.
Failure to Provide Scheduled ADL Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs) independently, specifically in maintaining good nutrition, grooming, and personal and oral hygiene. This deficiency was observed in two residents who did not receive their scheduled showers or bed baths as required. Resident #2, a cognitively intact male with a history of stroke and other medical conditions, reported not receiving bed baths according to his schedule due to staff shortages. He expressed dissatisfaction with the situation, having last received a bed bath on a specific date, despite his requests for assistance. Resident #1, who had moderate cognitive impairment and required substantial assistance with ADLs, also did not receive regular showers or bed baths. The facility's records showed a lack of documentation for showering tasks over the past 30 days, with only one bed bath recorded for Resident #1 during this period. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed a lack of awareness regarding the issue and confirmed that showers were not scheduled in the electronic care system, leading to a failure in documentation and task completion. The DON and other staff members acknowledged the oversight in scheduling and documenting showers, which resulted in residents not receiving the care they needed. The facility's policy on supporting ADLs emphasized the importance of providing appropriate care and services to maintain residents' hygiene and well-being. However, the failure to adhere to this policy and ensure proper documentation and scheduling of showers contributed to the deficiency observed by the surveyors.
Failure to Secure Resident's Medical Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records. During an observation, a computer displaying wound care information for a resident was left unlocked and unattended at the nurse's station. This occurred while the Licensed Vocational Nurse (LVN) responsible for the computer walked away to check on the resident's wound status. During the time the computer was unattended, two residents and a visitor passed by the nurse's station, potentially exposing the resident's sensitive medical information. The resident involved was a cognitively intact male with a history of cerebral infarction, hemiplegia, Type II diabetes, atrial fibrillation, cellulitis, and a congenital pancreatic cyst. The LVN admitted to forgetting to lock the computer, acknowledging that this action violated the resident's privacy. The Director of Nursing (DON) and the Administrator were not initially aware of the incident but confirmed that it was against the facility's policy and expectations for staff to leave resident information unsecured.
Improper Storage of Medication in Resident's Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. This deficiency was observed in the case of a resident who had a packaged syringe labeled 0.9% sodium chloride and several alcohol swabs left on his bedside table. The resident, who was cognitively intact, reported that the facility nurses used the saline solution in his port and often left items in his room. This oversight was confirmed during an interview and observation with LVN A, who was unaware of the syringe being left in the resident's room. Further investigation revealed that LVN D, the resident's assigned nurse for the shift, had used the saline flush for the resident's central line before and after medication administration. However, LVN D did not recall leaving the flush in the room and acknowledged it was her responsibility to remove all medications and biologicals from the resident's room. The DON was informed of the incident and stated that it was against the facility's expectations for medication supplies to be left in a resident's room, as they could be contaminated or misused. The facility's policy on the storage of medications, revised in April 2007, mandates that drugs and biologicals be stored in a safe, secure, and orderly manner. The policy specifies that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary manner. Despite this policy, the incident with the saline flush syringe indicates a lapse in adherence to these guidelines, potentially placing residents at risk of medication misuse.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in one of the resident rooms. During an observation and interview, a resident was found lying in bed with gnats flying off of him, indicating a pest issue in the room. The resident, who was nonverbal but able to answer yes and no questions, confirmed the presence of gnats and mentioned having reported the issue to staff, although he could not specify to whom. Despite the resident's report, the Licensed Vocational Nurse (LVN) and the Director of Maintenance (DOM) were unaware of the pest problem in the room. The facility's pest control program involved a pest control company visiting the facility monthly, with no reports of pests documented in the maintenance logs for the months reviewed. The DOM was responsible for pest control and expected staff to document pest concerns in the pest control binder or report them directly to him. However, the lack of awareness and documentation of the gnat issue in the resident's room suggests a breakdown in communication and reporting within the facility's pest control program.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted on a daily basis, as required, for one of the twenty-one days reviewed. On 05/17/24, observations at multiple times throughout the day revealed that the daily nursing staff posting near the dining room displayed the date of 05/16/24, indicating that it had not been updated. This oversight was confirmed during an interview with the Director of Nursing (DON), who was unaware that the posting had not been updated for the current day. The DON explained that the Assistant Director of Nursing (ADON) was responsible for updating the postings daily and typically provided staffing sheets in two-week increments at each pay period. However, the ADON had not provided the necessary sheets for the current pay period. The Administrator (ADMIN) also confirmed that the nurse staffing posting had not been updated for 05/17/24 and acknowledged that it should have been updated at the start of the day. The ADMIN stated that both the ADON and the receptionist were responsible for updating the daily nurse staffing posting. Despite the oversight, the ADMIN believed that residents were not affected as they did not pay attention to the posting, but acknowledged that they would be misinformed if the post was not updated daily. A related policy was requested from the ADMIN but was not provided before the exit.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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