Southern Oaks Therapy And Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 3350 Bonnie View Rd, Dallas, Texas 75216
- CMS Provider Number
- 745056
- Inspections on file
- 14
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Southern Oaks Therapy And Living Center during CMS and state inspections, most recent first.
Two CNAs failed to follow the facility’s infection control policies during incontinence care for two residents. One resident, who had a feeding tube and was on enhanced barrier precautions, received care from CNAs who entered the room without gowns, donned gloves without prior hand hygiene, performed perineal care including handling stool and soiled briefs, and then applied a clean brief without changing gloves or performing hand hygiene, leaving the room without washing their hands. Immediately afterward, the same CNAs provided incontinence care to another resident with bladder incontinence, again donning gloves without hand hygiene, cleansing the perineal area and removing a heavily urine-soaked brief, then applying a clean brief without changing gloves or washing hands, and exiting without hand hygiene. In interviews, both CNAs acknowledged knowledge of hand hygiene and PPE expectations but cited forgetting or lack of clarity, and the ADON confirmed that the CNAs’ actions did not meet facility policy or her expectations, noting that one CNA had not yet received infection control training.
Surveyors found that staff did not maintain accessible call lights for four residents with conditions including contractures, hemiplegia, epilepsy, polyneuropathy, mobility limitations, and varying levels of cognitive impairment. Each resident’s care plan required that the call light be kept within reach due to dependence on staff for ADLs and fall risk, yet observations showed call lights on the floor, coiled on the bed frame out of reach, or hung on a repositioning bar that was difficult for a resident to access. Residents reported being unable to find or easily reach their call lights, while staff interviews confirmed that call lights are essential for residents to request assistance and that staff are responsible for ensuring accessibility, contrary to the facility’s written policy requiring accessible call systems at bedside.
A resident with dementia, hemiplegia, hemiparesis, and moderate cognitive impairment, who was incontinent and care planned to prevent skin breakdown, was found in bed with a tube of barrier cream left on the bedside table, visible and accessible to the resident and others. The resident stated staff used the cream during incontinence care and sometimes left it on the side table. An LVN acknowledged the cream should have been stored in the treatment cart and not within the resident’s reach. The ADON and Administrator both stated that medications should not be stored in residents’ rooms and that staff were expected to scan rooms for medications, consistent with the facility’s policy requiring all medications and biologicals to be stored in locked compartments.
A resident with prostate CA, a documented cognitive communication deficit, and partial visual impairment was admitted for rehab with a family member designated as responsible party, who signed all admission documents. Despite this, the administrator later called the resident alone into the office, presented a NOMNC, and had the resident sign it without notifying or involving the designated representative, even though the resident reported not understanding what he was signing and relying on family to handle his paperwork. The responsible party stated she was not informed of the discharge notice and only learned of it when the resident called saying he had signed papers and was being put out, while facility records and staff interviews showed the EHR listed a family responsible party and that prior instructions at admission were to have the family sign because the resident probably would not understand the documents.
A cognitively intact female resident with bladder incontinence and on antibiotic therapy for UTIs returned from the hospital overnight and received incontinence care once in the early morning but was then left in a wet brief for over seven hours. Despite activating her call light and being told by a nurse that a CNA would assist, no one returned to change her. The CNA assigned to her admitted not having checked on her since starting the shift, while the RN and DON stated staff were expected to round every 2–3 hours and provide incontinence care at least every 2 hours or when wet, consistent with the facility’s neglect policy.
A CNA did not change soiled gloves or perform hand hygiene as required during incontinence care for a resident, instead continuing care and assisting with repositioning and dressing while wearing soiled gloves. The CNA only washed hands after completing all care, despite having received training on proper infection control procedures. Interviews confirmed that these actions were not in line with facility policy and expectations.
A resident with a colostomy and complex medical needs was found to have soiled linen left on the floor and bodily substances smeared on the wall and floor in their room. Staff interviews confirmed that proper protocols for handling contaminated linen were not followed, and there was a lack of timely communication to facility leadership about the incident. The facility's own policies for managing soiled laundry were not adhered to, resulting in a failure to maintain a clean and safe environment.
A resident with a colostomy and multiple complex diagnoses was readmitted from the hospital, but physician orders for ostomy care were not reactivated, and nursing staff did not consistently document the provision of colostomy care. This resulted in a lack of verification that required care was provided, contrary to facility policy and professional standards.
The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats in various areas, including the nurse's stations, kitchen, and dining room. Staff reported the issue but lacked a system for reporting sightings, and the new administrator acknowledged the problem, contacting a pest control company for assistance. Despite efforts, the pest issue persisted, with no pest control log or communication system in place.
The facility failed to maintain wheelchairs for eight residents, with issues such as cracked armrests and missing parts, posing safety risks. Additionally, the clean utility room was repeatedly left unlocked, allowing unauthorized access to medical supplies. Staff interviews revealed a lack of communication and procedures for reporting and repairing broken wheelchairs, with the new Administrator only recently addressing the issue.
The facility failed to secure medications and medical supplies, with an unlocked treatment cart on Hall 500 and an open clean utility room on Hall 200. LVN A admitted to leaving the cart unlocked due to confusion over responsibilities, while the utility room was accessed by an unidentified staff member and a resident. Interviews with the ADON and DON confirmed the need for locked storage to prevent harm.
The facility failed to follow professional standards for food safety, with unlabeled and improperly stored food items in the refrigerator and incorrect thawing practices observed in the kitchen. A block of cheese and dry cereal were found unsealed and without proper labeling, while a pan of chicken was improperly thawed in a sink without running water, contrary to the facility's policy.
A facility failed to maintain proper infection control practices. A CNA did not perform hand hygiene between glove changes during incontinence care, and an MA used personal scissors to cut lidocaine patches without cleaning them. Both actions were against facility policies, risking cross-contamination.
The facility failed to maintain a safe and sanitary environment, with issues such as a loose handrail and missing tiles in key areas. Staff interviews revealed inconsistent use of the maintenance logbook, with many issues reported verbally. High turnover in maintenance management may have contributed to these deficiencies.
A resident with multiple diagnoses did not receive recommended PASRR services, including habilitative therapy and a customized wheelchair, due to administrative delays and financial issues. The MDS coordinator and Director of Rehabilitation were aware of the recommendations, but the previous administrator did not approve the services. The new administration eventually ordered the equipment, but the delay affected the resident's mobility and comfort.
The facility failed to update care plans for three residents, leading to potential risks in care delivery. A resident's care plan was not revised to reflect the discontinuation of a condom catheter, another resident's plan did not include changes from a motorized to a manual wheelchair, and a third resident's plan lacked updates for a specialized wheelchair and habilitative services. Staff interviews revealed a lack of awareness and follow-up on these necessary updates.
Failure to Follow Hand Hygiene and PPE Requirements During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to hand hygiene and use of personal protective equipment (PPE) during incontinence care for two residents. Resident #1, a cognitively intact male with hypertension, aphasia, a feeding tube, and a wound, was on enhanced barrier precautions as reflected in his care plan. His care plan required proper signage, availability and use of PPE including gowns and gloves during high-contact care, and adherence to enhanced barrier precautions. Resident #2, a cognitively intact female with bilateral knee contractures and bladder incontinence, had a care plan directing staff to check for incontinence and to wash, rinse, and dry the perineal area and change clothing as needed after incontinence episodes. On the observed date, CNA B and CNA C entered Resident #1’s room to provide incontinence care. Both CNAs donned gloves without performing hand hygiene. Despite an enhanced barrier precaution sign and PPE available outside the room, neither CNA donned a gown before entering. CNA B cleansed Resident #1’s abdominal folds and perineal area using wet wipes and then turned the resident to clean his buttocks and thighs. The resident was noted to be wet and to have had a bowel movement; CNA B removed the soiled brief and discarded it. Without performing hand hygiene or changing gloves after handling the soiled brief and completing perineal care, CNA B applied a clean brief. Both CNAs then removed their gloves, took the trash, exited the room, and did not wash their hands. CNA B took the trash to the soiled closet and then proceeded directly to Resident #2’s room without hand hygiene. In Resident #2’s room, CNA B initially went to wash her hands but left before doing so to retrieve another bag of trash from Resident #1’s room, placed it in the soiled closet, and returned to Resident #2’s room. Without washing her hands, she donned gloves and prepared supplies; CNA C also donned gloves without hand hygiene. CNA B then cleansed Resident #2’s abdominal folds and perineal area, turned the resident to clean the buttocks and thighs, and removed a heavily urine-soaked brief. Without performing hand hygiene or changing gloves after handling the soiled brief, she applied a clean brief. Both CNAs positioned the resident, removed their gloves, took the trash, and left the room without washing their hands. In interviews, CNA C acknowledged she knew she was supposed to perform hand hygiene before resident contact, between care, and after glove removal, and to wear gowns for residents on enhanced barrier precautions, but stated she forgot. CNA B stated she knew she should perform hand hygiene before and after care and with each glove change but did not know she was supposed to change gloves between care, and admitted she did not wash her hands or change gloves between residents or between handling soiled and clean briefs, stating she had no reason and often forgot PPE when in a hurry. The ADON confirmed her expectation that staff perform hand hygiene before resident contact, between care, and with glove changes, and wear PPE for residents on enhanced barrier precautions, and acknowledged that CNA B had been employed for three weeks without receiving infection control training, despite facility policies requiring staff training and adherence to hand hygiene and PPE use.
Failure to Maintain Accessible Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to reasonable accommodation of needs and preferences by not maintaining accessible call lights for four residents. For one resident with contractures, hemiplegia, hemiparesis, moderate cognitive impairment, and dependence on staff for all ADLs, the comprehensive care plan required that the call light be within reach. During observation, this resident was in bed awake with the call light lying on the floor; she stated she used the call light to call staff, did not have it, could not find it, and that this was not the first time she could not find her call light. Another resident, with epilepsy, muscle wasting, lack of coordination, unsteadiness of feet, severe cognitive impairment, and needing assistance with transfers, bed mobility, toileting, showering, dressing, and hygiene, also had a care plan intervention to keep the call light within reach and was identified as at risk for falls. During observation, this resident was in bed awake with the call light coiled on the lowest bed frame, not within reach, and did not respond when asked where the call light was. A third resident, with difficulty walking, epilepsy, repeated falls, and a fracture, had a care plan intervention to keep the call light within reach following an actual fall. This resident was observed awake in bed with the call light on the floor and stated it had been on the floor since morning and staff had not returned it to the bed. A fourth resident, with obesity, polyneuropathy, intact cognition, and needing assistance with dressing, transfers, bed mobility, hygiene, and showering, was care planned as at risk for falls with an intervention to keep the call light within reach. This resident was observed awake in bed with the call light hanging on the repositioning bar; she reported staff always hung it there and that it was difficult for her to turn to get it, expressing a desire for it to be placed where it was easier to reach. Multiple staff, including LVNs and CNAs, acknowledged during interviews that call lights are important for residents to call staff when they need something or need assistance, and that staff are responsible for ensuring call lights are within residents’ reach. The facility’s written policy on call lights required that the call system be accessible to residents while in bed or other sleeping accommodations, which was not followed in these observed instances.
Improper Storage of Barrier Cream Left Accessible at Bedside
Penalty
Summary
The facility failed to store medications and biologicals in locked compartments and under proper controls, and failed to limit access to medications to authorized personnel, as required by State and Federal laws and facility policy. A resident with dementia, hemiplegia, hemiparesis, and moderate cognitive impairment (BIMS score of 09), who was incontinent of bowel and bladder and care planned to remain free from skin breakdown, was observed in bed with a tube of barrier cream left on the bedside table. The cream was visible and accessible to the resident and others in the room. The resident reported that staff used the cream when cleaning and changing her and that some staff sometimes left the tube on her side table. During subsequent observations and interviews, an LVN stated she did not know who left the barrier cream in the room and acknowledged that the tube should have been stored in the treatment cart or otherwise out of the resident’s reach. She indicated that residents might use the cream more than recommended or, if confused, might consume it. The ADON stated that medications should not be stored in residents’ rooms and that the tube of wound dressing cream should have been in the nurse’s cart and not within reach of any resident. The Administrator similarly stated that staff were expected to look around residents’ rooms for any medications, as residents could consume or use medications inappropriately if left at bedside. Review of the facility’s Medication Labeling and Storage policy reflected that all medications and biologicals were to be stored in locked compartments, which was not followed in this instance.
Failure to Involve Designated Representative in NOMNC and Discharge Preparation
Penalty
Summary
The deficiency involves the facility’s failure to provide and document sufficient preparation and orientation for a safe and orderly discharge, and failure to ensure that a resident’s designated representative was notified and involved when a Notice of Medicare Non-Coverage (NOMNC) was issued and signed. The resident was an older male admitted for rehabilitation with diagnoses including prostate cancer and a cognitive communication deficit. His admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that he was usually understood, usually understood others, and had adequate vision, though he required supervision or touch assistance with most ADLs. The care plan did not address any need for a representative’s involvement in decision-making, despite the electronic health record listing a family member as the resident’s responsible party and the admission agreement being signed by that family member as the designated representative. The Administrator met with the resident in his office, with the receptionist present, and presented the NOMNC, documenting that the last covered day and discharge date were explained and that the resident was asked about home health and discharge location. The NOMNC form showed that the Administrator notified the resident of the notice and that the resident signed it, with information that he could appeal if he disagreed. However, the Administrator did not notify or involve the resident’s designated responsible party at the time the NOMNC was issued or signed, even though the responsible party had signed all prior admission documents on the resident’s behalf. The Administrator later stated he considered the resident to be his own responsible party and believed the resident comprehended the NOMNC and appeal process, despite acknowledging he did not know why the resident was not listed as his own responsible party in the EHR or why he had not signed his own admission documents. The resident’s responsible party reported that she had been handling all of the resident’s business with the facility because he was heavily medicated, not coherent enough, and unable to read well, and that she had signed all prior documents. She stated she was not notified of the discharge notice, was not provided the NOMNC to sign, and only learned of it when the resident called and said he had to sign papers and was being “kicked out.” The resident stated he was partially blind in one eye from a cataract, was not comfortable reading, and allowed his family to handle his business. He reported that the Administrator stopped him on his way to the dining area, took him into the office, told him he had to sign some paperwork, and that he did not understand what he was signing but signed because he was told he had to. The receptionist confirmed she had been instructed by the former BOM at admission to have the family sign the admission agreement on the resident’s behalf because the resident probably would not understand what he was signing. The facility’s transfer and discharge policy required that transfer/discharge notices be provided to the resident and the resident’s representative in a language and manner they can understand, and CMS NOMNC instructions require that if an enrollee cannot comprehend the notice, it must be delivered to and signed by a representative. These requirements were not followed in this case.
Failure to Provide Timely Incontinence Care Resulting in Prolonged Wetness
Penalty
Summary
A cognitively intact female resident with a history of brain bleed, back pain, type 2 diabetes, bladder incontinence, and current antibiotic therapy for UTIs was admitted to the facility and returned from the hospital via ambulance late at night. Her care plan documented bladder incontinence with an intervention to check as required for incontinence. The resident reported she received incontinence care around 4–5 AM after returning around midnight, and by late morning she remained in a wet brief, stating she had not been changed again and that this was causing her distress. She also stated she was usually out of the facility in the mornings for therapy at another location and was present that morning only because she had just been discharged from the hospital. By early afternoon observation, the resident was still unchanged, indicating she had been left in the same brief for more than seven hours. The resident reported she had activated her call light about an hour earlier, a nurse had responded and said an aide would assist, but no one returned to provide incontinence care. The CNA assigned to the resident acknowledged she had not yet checked on the resident since coming on duty at 6 AM, stating she was busy and believed the resident had just returned from the hospital. The RN assigned to the resident stated CNAs were expected to make rounds every 2–3 hours and residents should be changed every 2 hours or when wet or soiled, and the DON confirmed the expectation that residents be checked every 2 hours and never left wet for more than 4 hours, noting that nurses could also provide incontinence care when CNAs were busy. The facility’s Abuse & Neglect policy defined neglect as deprivation of goods and services that would cause emotional distress.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident. The CNA donned clean gloves and a gown after using hand gel in the hallway, then proceeded to provide incontinence care, including cleaning the resident's pubic, genital, and rectal areas. Throughout the process, the CNA did not change soiled gloves or perform hand hygiene between tasks, even after handling soiled materials and repositioning the resident. The CNA continued to assist with repositioning and dressing the resident while wearing soiled gloves, and only removed the gloves and gown at the end of care, washing hands afterward. Additionally, after removing dirty gloves, the CNA did not perform hand hygiene before donning new gloves and continued to assist with the resident's clothing and linens. Interviews with the CNA and the Director of Nursing (DON) confirmed that the facility's expectation and policy require hand hygiene before and after care, and glove changes after removing dirty gloves. The CNA acknowledged awareness of these procedures but did not follow them during the observed care, attributing the lapse to nervousness and distraction. Review of facility policies and recent in-service training indicated that the CNA had been trained on proper hand hygiene and infection control practices, including the requirement to wash hands after removing gloves and before direct contact with residents.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident, as evidenced by soiled linen being placed on the floor and the presence of a brown smeared substance on the wall above the linen. Additionally, dried brown substances and yellow liquid stains were observed on the floor next to the resident's bed. These conditions were documented through a photo and video provided by an anonymous employee, which showed the state of the room during the overnight shift. At the time of the surveyor's observation, the room was found to be clean, but the earlier evidence indicated a lapse in maintaining cleanliness and proper handling of soiled materials. The resident involved had a complex medical history, including colostomy status, hepatic encephalopathy, congestive heart failure, and end-stage renal disease. The resident was cognitively intact and had a care plan addressing behavioral issues related to the removal of his ostomy bag. Staff interviews confirmed that the resident had a pattern of removing his colostomy bag, which sometimes resulted in bodily fluids contaminating linens and potentially the environment. Despite this known behavior, staff did not consistently follow protocols for handling soiled linen, as soiled items were left on the floor rather than being immediately bagged and removed according to facility policy. Multiple staff members, including CNAs, LVNs, the ADON, and the DON, acknowledged that soiled linen should not be left on the floor and described the correct procedures for handling contaminated materials. However, there was a lack of clarity regarding who was responsible for the incident, and communication breakdowns were evident, as the DON and other leadership were not made aware of the situation until after the fact. The facility's policy required all soiled laundry to be handled as potentially contaminated, bagged at the location of use, and not sorted or rinsed in resident rooms, but these procedures were not followed in this instance.
Failure to Reactivate and Document Colostomy Care Orders After Resident Readmission
Penalty
Summary
The facility failed to provide colostomy care in accordance with professional standards and its own policies for a resident with a colostomy. Upon the resident's readmission from the hospital, physician orders for ostomy care, including changing the ostomy bag every three days, cleansing the area every shift, and emptying the bag every shift, were not reactivated. As a result, there were no active orders or documentation of ostomy care provided from the time of readmission until the orders were reinstated over three weeks later. During this period, nursing staff did not document the provision of colostomy or ileostomy care as required by facility policy. Interviews with nursing staff and administration confirmed that care may have been provided, but it was not consistently documented, and some staff admitted to not always recording the care they performed. The lack of documentation meant that there was no way to verify if the resident received the necessary ostomy care or if any issues were identified and addressed. The resident involved had a complex medical history, including colostomy status, hepatic encephalopathy, congestive heart failure, and end-stage renal disease. The resident was cognitively intact and did not refuse care. Facility records and staff interviews confirmed that the failure to reactivate orders and document care was contrary to both the facility's colostomy/ileostomy care policy and its charting and documentation policy, which require all treatments and services to be recorded in the medical record.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live flies and gnats in various areas, including the nurse's stations, kitchen, conference room, break room, and main dining room. Observations revealed flies and gnats in these areas, with flies seen crawling on leftover food and medication carts, and gnats around juice glasses. Staff interviews indicated that the pest issue was known, but there was no system in place for reporting sightings, and staff were unsure of how to address the problem. The facility's staff, including a medical assistant and a licensed vocational nurse, reported the persistent presence of flies and gnats since they began working at the facility. They noted that there was no pest control log or communication system in place, and they were not aware of any pest control personnel visiting the facility. The dietary manager confirmed that despite efforts to keep flies out, they remained a problem in the kitchen, and residents in a group meeting expressed that the issue had worsened over the past six months. The new administrator acknowledged the pest problem and stated that she had contacted a pest control company for immediate assistance. However, it was noted that there was no pest control book available for staff to report issues, and the facility was in the process of hiring a new maintenance person. The facility's policy, revised in July 2013, stated that an ongoing pest control program should be maintained, but this was not effectively implemented, leading to the deficiency.
Facility Fails to Maintain Wheelchairs and Secure Utility Room
Penalty
Summary
The facility failed to ensure that all assistive devices were maintained and free of hazards, specifically concerning the maintenance of wheelchairs for eight residents. Observations revealed that several wheelchairs had cracked armrests with exposed foam, missing armrests, and dried food substances on the wheels and back of the wheelchairs. These deficiencies were noted for residents with varying degrees of cognitive impairment and physical disabilities, including dementia, schizophrenia, muscle weakness, and other conditions requiring wheelchair mobility. Despite the residents' reliance on these wheelchairs for mobility, the facility did not maintain them in a safe and functional condition. Additionally, the facility failed to secure the clean utility room on Hall 200, which was repeatedly observed to be left unlocked and open. This room contained various medical supplies and equipment, including syringes, needles, catheters, and nutritional formulas, which were accessible to unauthorized individuals, including residents. Interviews with staff revealed a lack of awareness and responsibility regarding the security of the utility room, with some staff members unsure of who had access to the keys. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Registered Nurse (RN), Licensed Vocational Nurse (LVN), and the Assistant Maintenance person, highlighted a lack of communication and procedures for reporting and repairing broken wheelchairs. The new Administrator, who had only been in the position for two days, identified the issue and ordered parts for repairs. However, prior to this, there was no maintenance log or system in place to address the repair needs of wheelchairs, indicating a systemic failure in maintaining essential equipment for resident safety.
Medication and Supply Security Lapses
Penalty
Summary
The facility failed to ensure the security of medications and medical supplies, as observed during a survey. On Hall 500, a treatment cart was left unlocked and unattended in the hallway, outside of a resident's room. LVN A admitted to forgetting to lock the cart after retrieving supplies, acknowledging that the cart should always be locked to prevent unauthorized access to medications. This oversight was attributed to confusion over the responsibility of charge nurses completing their own treatments on the hallways. Additionally, the clean utility room on Hall 200 was repeatedly found unlocked and open throughout the morning, despite a sign instructing that it should be kept closed and locked when not in use. The room contained various medical supplies, including suction equipment, nutritional formulas, catheters, syringes, and medications. An unidentified staff member and a resident were observed accessing the room, with the staff member noting that the door should be locked and expressing uncertainty about who had keys to the room. Interviews with the ADON and DON confirmed that both the treatment carts and the clean utility room should be locked when not in use to prevent potential harm to residents. The DON mentioned plans for additional in-services to remind staff of the importance of securing medications. The Administrator also emphasized that it is basic nursing practice to keep treatment carts locked when not in use, and that staff using the carts are responsible for ensuring they are secure.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. During an inspection of the walk-in refrigerator, it was noted that a partially used block of cheese was stored in an unsealed bag without any labeling to indicate its contents, the date it was placed in the bag, or its use-by date. Additionally, two storage bags containing dry cereal were found unsealed, with only a date opened marked on them, but no expiration date. These lapses in labeling and sealing food items are contrary to the facility's policy, which requires all foods to be stored wrapped or in covered containers, labeled, and dated to prevent cross-contamination. Further observations revealed improper thawing practices. A pan of chicken was found in a large sink, immersed in water, but the water was not running, which is against the facility's policy that requires food to be thawed under running water to prevent contamination. The Dietary Manager (DM) acknowledged the error and stated that staff are expected to thaw items in the refrigerator. The cook admitted to turning off the water out of habit and acknowledged the importance of proper food handling to prevent illness. The facility's Food Storage Policy, revised in February 2023, outlines specific procedures for thawing frozen items, which were not followed in this instance.
Infection Control Deficiencies in Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA C and MA D. CNA C was observed providing incontinence care to a resident without performing proper hand hygiene between glove changes. During the care, CNA C changed gloves multiple times without washing hands or using hand sanitizer, which is against the facility's policy. This lapse in protocol occurred despite CNA C acknowledging the importance of hand hygiene to prevent the spread of infection. Additionally, MA D was observed using personal scissors to cut lidocaine patches for a resident without cleaning the scissors before or after use. This action was contrary to the facility's policy on cleaning and disinfecting resident-care items. MA D admitted to not considering the need to clean the scissors, which could potentially lead to cross-contamination. The Director of Nursing confirmed the expectation for staff to perform hand hygiene and clean equipment to prevent cross-contamination.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in two of its halls, the nursing station area, the Central Supply, and the dining area. Observations revealed that a handrail near the Central Supply Room in the 500 hall was separated from the wall, creating a gap. Additionally, tiles near the central Nursing Station and in the dining area were loose or missing, exposing the concrete floor beneath and allowing a buildup of a black substance. These issues were not recorded in the facility's maintenance log, indicating a lack of formal reporting and tracking of maintenance needs. Interviews with staff, including CNAs and the Maintenance Tech, revealed that while there was a maintenance logbook intended for reporting issues, it was not consistently used. Staff often reported issues verbally, and the Maintenance Tech was unaware of some of the problems, such as the loose handrail. The facility had experienced high turnover in maintenance management, with five managers in six months, which may have contributed to the lack of attention to these environmental deficiencies. The ADM, who was new to the facility, was also unaware of the specific issues but expected the maintenance logbook to be used for reporting.
Failure to Implement PASRR Recommendations for Resident
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR evaluation report into the care planning and transition of care for a resident with cerebral palsy, intellectual disability, bipolar disorder, and scoliosis. The resident was supposed to receive habilitative services, including physical therapy, occupational therapy, and a customized wheelchair, as recommended during an IDT meeting. However, these services were not provided within the required timeframe, which could potentially impact the resident's physical, mental, and psychosocial well-being. Interviews revealed that the MDS coordinator was aware of the recommendations and had completed the necessary paperwork, but the resident had not received the habilitative therapy or the customized wheelchair. The Director of Rehabilitation confirmed that the previous administrator had refused to order the wheelchair or contact the DME company, citing financial constraints due to the company's bankruptcy. The new administration eventually ordered the equipment, but the delay had already affected the resident's mobility and comfort. The resident expressed dissatisfaction with the current wheelchair, which was not customized and did not fit properly, leading to reduced mobility. Staff interviews corroborated that the resident was waiting for the specialized wheelchair and had not been receiving the recommended therapies. The previous administrator admitted to not approving the services due to financial issues, while the new administrator acknowledged the oversight and took steps to rectify the situation.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the person-centered comprehensive care plans for three residents, which could place them at risk for not receiving appropriate care. Resident #52's care plan was not updated to reflect the discontinuation of a condom catheter, despite physician orders indicating it was no longer medically necessary. This oversight occurred even though the care plan had been edited after the catheter was discontinued. Resident #53's care plan was not revised to include goals and interventions for the transition from a motorized wheelchair to a manual wheelchair. This change was recommended for safety reasons due to the resident's poor trunk control, as noted in occupational therapy assessments. Despite these recommendations, the care plan did not reflect the necessary updates to address the resident's current mobility needs. Similarly, Resident #65's care plan lacked updates to reflect the need for a specialized wheelchair and habilitative services, as recommended during a PASRR meeting. The care plan did not include goals and interventions for this change, which was necessary due to the resident's condition. Interviews with facility staff revealed a lack of awareness and follow-up on these care plan updates, contributing to the deficiencies identified.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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