Terra Bella Health And Wellness Suites
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 12262 Cityscape Ave, Houston, Texas 77047
- CMS Provider Number
- 676450
- Inspections on file
- 46
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 17 (3 serious)
Citation history
Health deficiencies cited at Terra Bella Health And Wellness Suites during CMS and state inspections, most recent first.
A resident with dementia, severely impaired cognition, limited range of motion, and bowel and bladder incontinence received incontinent care during which a CNA was repeatedly observed on video throwing used disposable pads onto the floor instead of properly disposing of them. The facility’s Infection Preventionist stated that soiled or wet pads should be placed in a clear plastic bag and sent to the laundry or utility closet, and that placing them on the floor was an infection control issue, particularly when contaminated with urine or feces. These actions conflicted with the facility’s linen and laundry policy requiring sanitary handling of soiled linen and adherence to universal/standard precautions.
A newly hired CNA on her first orientation day was allowed to assist a resident with dementia, muscle wasting, and dysphagia with eating without supervision, despite the resident’s care plan requiring substantial/maximal assistance and specific positioning to reduce choking and aspiration risk. The CNA provided hands-on feeding for a period reported to be up to 45 minutes alone, contrary to the ADON’s description that first-day orientation should be shadowing only and the facility’s CNA orientation policy requiring instruction on skill weaknesses before performing tasks.
A resident with a left foot wound and heel infection was assisted with a shower before a wound care appointment, during which the wound dressing became wet despite physician's orders to keep it dry. The resident was sent to the appointment with the wet dressing, and staff interviews confirmed the dressing should have been changed if wet, indicating a failure to follow professional standards and the care plan.
A resident with severe cognitive impairment and limited mobility was transferred using a mechanical lift by only one staff member, contrary to standard practice requiring two staff. The resident was suspended and swinging in the air during the transfer, which was observed on video and confirmed by the DON. The facility's policy did not specify the required number of staff for such transfers.
A nurse failed to follow physician orders and facility policy by administering multiple enteral medications as a single mixture instead of separately with warm water flushes for a resident with a gastrostomy tube. This action was inconsistent with the resident's care plan and established nursing protocols, as confirmed by staff interviews and record review.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions. Review of documentation showed incomplete planning and insufficient detail to ensure comprehensive care.
The facility did not ensure that each resident received an accurate assessment, resulting in incomplete or incorrect evaluations necessary for determining appropriate care and services.
A medication cart containing OTC and prescription medications, syringes, lancets, and pen needles was found unlocked and unattended in a hallway. An LVN left the cart unsupervised after being interrupted during medication pass, contrary to facility policy requiring carts to be locked when not in use. The Interim DON confirmed that this practice was not in accordance with established procedures to prevent unauthorized access.
A resident with dysphagia and severe cognitive impairment was served a mechanical soft meal instead of the physician-ordered pureed diet. The dietary aide misread the meal ticket and placed the wrong food on the tray, which was then delivered and partially fed to the resident by a CNA before the error was discovered by a nurse. The incident involved failures by both dietary and nursing staff to verify the correct diet consistency before serving and feeding.
A resident developed a stage 3 sacral pressure ulcer and an unstageable pressure injury due to the facility's failure to provide adequate pressure ulcer care and prevention. Despite the resident's risk factors, staff did not follow protocols for skin assessments and wound interventions, leading to a delay in care. Communication breakdowns and lack of documentation contributed to the oversight, placing the resident at risk of pain and infection.
A resident with multiple medical conditions, including dementia and functional quadriplegia, was found with a thick accumulation of a brown, flaky substance on her scalp and matted hair that required cutting. The facility failed to document or address these grooming deficiencies, and there was no communication with the resident's responsible party or physician. The lack of proper care placed the resident at risk for scalp issues and infection.
A wound care nurse announced from the hallway that she was about to perform wound care on a resident's sacrum, with the door half-open and within hearing range of others. The resident, who is cognitively intact and fully dependent due to quadriplegia and other conditions, was not aware of the announcement but stated he would not want others to know about his care. The facility's policy requires auditory privacy during treatment, and the administrator confirmed this was a dignity concern.
A resident with a stage 4 pressure ulcer received wound care from a nurse who failed to change gloves between cleansing the wound and applying the new dressing, and did not allow hand sanitizer to dry before donning gloves. The nurse admitted to not following facility policy, and the facility's wound care checklist required glove changes and proper hand hygiene, which were not followed during the procedure.
The facility's kitchen failed to store and label a 13.7-quart container of brown sugar according to professional standards, leaving it open to potential contamination. Staff interviews confirmed the risk of contamination and illness due to the unlabeled and unsealed container, which violated the facility's Nutrition Policies and Procedures.
A facility failed to coordinate PASRR assessments for a resident with mental illness, not identifying her condition in the PASRR Level 1 Screening. The resident had diagnoses of metabolic encephalopathy, depression, and anxiety disorder, and was on antidepressant medications. The MDS Coordinator acknowledged the oversight, noting the process involved verifying diagnoses and filling out form 1012 for discrepancies. The Corporate MDS Nurse confirmed the facility's responsibility in ensuring accurate PASRR screenings and necessary psych services.
The facility failed to secure the lid of one of its dumpsters, as observed during a survey. This non-compliance with the facility's waste disposal policies could attract pests, posing a potential safety issue for residents. Interviews with the Cook and Dietary Manager confirmed awareness of the requirement to keep dumpster lids closed.
A facility failed to ensure a resident with a G-tube received appropriate care, as RN A did not verify tube placement by aspirating stomach contents before administering water flushes and medications. Instead of using gravity, RN A used a syringe plunger, contrary to standards of practice. The resident, with a history of neurological conditions and dysphagia, was at risk due to these actions, which were confirmed by the DON.
A resident with COPD did not receive proper respiratory care as their oxygen tubing was not labeled or dated, and the humidifier was improperly connected. Staff interviews revealed non-compliance with the facility's oxygen therapy policy, risking infection and respiratory distress.
The facility failed to accurately assess and document behaviors for two residents on their MDS assessments. One resident, with multiple diagnoses including schizophrenia, refused care multiple times, yet her MDS showed no behavioral symptoms. Another resident with dementia and anxiety also refused care, but her MDS inaccurately reflected no behaviors. Staff interviews revealed oversight in coding these behaviors, potentially risking inadequate care for the residents.
A resident with multiple medical conditions and cognitive impairment did not receive adequate assistance with ADLs, leading to poor personal hygiene. Observations showed long, dirty fingernails and matted hair, while staff interviews revealed inconsistencies in care and communication. The DON acknowledged the need for nail trimming and hair care, but the responsibility was not clearly assigned, resulting in the deficiency.
A facility failed to provide appropriate care for a resident with a hand contracture, neglecting to implement necessary interventions. The resident, with multiple health issues and severe cognitive impairment, was observed with a contracted hand lacking a hand roll, and poor hygiene. Staff interviews revealed a lack of awareness and action regarding the resident's needs, and the care plan did not address the contracture. The facility's policies on joint mobility were not followed, leading to a significant oversight in care management.
A resident with severe cognitive impairment was found in an unsanitary condition, with urine-soaked items left on her wheelchair, leading to a strong ammonia smell in her room. The incident involved a new aide who forgot to remove the soiled linen, and the family member had difficulty addressing the issue with the weekend supervisor. The facility's grievance system recorded the incident, but no immediate corrective actions were noted.
The facility failed to provide necessary treatment and services for residents with pressure ulcers, leading to inadequate care for two residents. The facility did not follow physician orders, lacked essential supplies, and staff did not perform proper hand hygiene, increasing the risk of infection and worsening of pressure ulcers.
The facility failed to provide proper incontinence and catheter care, leading to increased risk of urinary tract infections. A CNA did not follow proper technique during incontinence care, and an ADON placed a catheter bag on the bed during wound care. Additionally, a resident's catheter strap was missing for a week, increasing the risk of urethral trauma and infection.
The facility failed to maintain an infection prevention and control program, leading to deficiencies in the care of two residents and the actions of two staff members. An ADON did not perform proper hand hygiene during wound care, and a CNA failed to change gloves and wash hands during incontinence care, risking cross-contamination and infections.
A resident with multiple medical conditions did not receive prescribed wound care medications due to a lapse in updating the electronic medical record and failure to follow physician orders. The ADON also did not maintain proper hand hygiene during the wound care procedure.
Improper Handling of Soiled Incontinent Pads During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program related to the handling of soiled incontinent pads for one resident. The resident was an older adult with dementia, severely impaired cognition, limited functional range of motion in both arms and legs, and was care planned as incontinent of bowel and bladder. Video review on three separate dates showed the same unidentified CNA providing incontinent care at the resident’s bedside and, during each episode, throwing a used disposable pad onto the floor instead of handling it according to infection control practices. The videos documented that during incontinent care, the CNA repeatedly discarded wet and/or soiled pads by throwing them onto the floor beside or behind her. The facility’s Infection Preventionist stated that soiled or wet pads should be placed in a clear plastic bag and sent to the laundry or utility closet, and that placing such items on the floor constituted an infection control issue, especially if contaminated with urine or feces. The facility’s written policy on Linen and Laundry Procedures required sanitary processing and storage of soiled linen and the use of universal/standard precautions by all personnel handling soiled linen. The observed staff actions were inconsistent with these stated procedures and expectations.
Unsupervised New CNA Assisted High-Risk Resident With Eating Without Demonstrated Competency
Penalty
Summary
The facility failed to ensure that a nurse aide demonstrated competency in skills and techniques necessary to meet a resident’s assessed needs and care plan requirements for safe eating assistance. The resident involved was an elderly individual with dementia, muscle wasting, dysphagia, severely impaired cognition, and limited functional range of motion in all extremities. Her Quarterly MDS documented that she required substantial/maximal assistance for eating, and her care plan identified her as being at risk for choking and aspiration related to difficulty swallowing, with instructions that her head of bed be elevated more than 45 degrees, with 90 degrees being optimal, during meals. On observation, the resident was receiving a pureed diet and required slow, assisted feeding with the head of bed elevated. Despite these needs, the facility allowed a newly hired CNA, on her first day of orientation, to assist this resident with eating without supervision. CNA F, who was assigned as the orienting CNA, reported that on the first day of orientation the new CNA assisted the resident with her meal and worked with her alone for 15 minutes. A family member later reported, based on video review, that the new CNA had worked with the resident for 45 minutes without supervision. The ADON stated that the first day of orientation should be shadowing only, with no hands-on care, and acknowledged that each resident has a profile that takes time to learn and that complications could arise from using the wrong technique or not following the care plan if staff are not properly trained. The facility’s own CNA orientation policy required appropriate instruction on any identified skill weaknesses prior to delivering or completing a task, which was not followed in this instance.
Failure to Maintain Dry Wound Dressing Prior to Medical Appointment
Penalty
Summary
A resident with a history of an unspecified wound on the left foot, left heel infection, and cognitive communication deficit was admitted to the facility. Physician's orders specified that the resident's wound dressing should not get wet during showers or baths, and that the area should be covered with a cast cover or plastic bag to prevent water exposure. On the day of a scheduled wound care appointment, the resident was assisted with a shower by a CNA, who reported wrapping the resident's left leg/foot in plastic. However, the resident's bandages were found to be wet upon arrival at the wound care appointment, as confirmed by a family member. The physician's orders also noted that the dressing had been soaked previously and reiterated the importance of keeping the dressing dry. Observation of wound care by an LVN later revealed that the dressings were dry and intact at that time, but the resident had open areas on the top of the foot and heel, with pain reported during the procedure. The DON confirmed in an interview that a wet dressing could lead to tissue breakdown and that the nurse should have changed the dressing if it was wet. The facility failed to ensure that the resident received care in accordance with professional standards and the comprehensive care plan, as the resident was sent to a medical appointment with a wet wound dressing, contrary to physician's orders.
Mechanical Lift Transfer Performed by Single Staff Member
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, contractures in both shoulders, and muscle wasting was transferred using a mechanical lift by a single staff member, despite the lift requiring two staff for safe operation. The resident, who was dependent on staff for all transfers and had limited functional range of motion in all limbs, was observed being lifted from a shower chair and moved approximately ten feet to her bed while suspended about three feet above the ground. During the transfer, the resident was visibly swinging as her weight shifted side to side. The Director of Nursing confirmed in an interview that two staff are required for mechanical lift transfers to prevent falls, but the facility's mechanical lift policy did not specify the number of staff required. The incident was captured on video, showing the single staff member performing the transfer and moving the resident through a 180-degree turn while she remained suspended in the air.
Failure to Administer Enteral Medications per Physician Order
Penalty
Summary
A deficiency occurred when a nurse failed to administer enteral medications according to physician orders for a resident with a gastrostomy tube. The nurse combined multiple medications into a single cup and administered them as a cocktail, rather than crushing and administering each medication separately with warm water as specified in the physician's order and facility policy. The nurse also did not use warm water for flushing the tube, as required by the order. The resident involved was an elderly female with multiple medical diagnoses, including unspecified dementia, gastrostomy status, hypertension, anemia, and hydronephrosis. Her care plan and medication administration record indicated that medications should be administered as ordered by the physician, with specific instructions to flush the tube with 30cc of warm water before and after administration. There was no order permitting the mixing of medications for enteral administration. Interviews with other nursing staff, the DON, and review of facility policies confirmed that the standard practice is to crush and administer each medication separately, flushing the tube with warm water between medications, unless otherwise ordered by a physician. Staff consistently stated that medications should not be mixed due to the risk of adverse reactions and tube clogging. The nurse involved acknowledged awareness of the correct procedure but attributed the error to nervousness during observation by a state surveyor.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all assessed needs or provide clear, measurable interventions.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which is required to determine the appropriate care and services for residents. Specific details about the residents involved, their medical history, or their condition at the time of the deficiency are not provided in the report. The deficiency centers on the inaccuracy of resident assessments, which are essential for planning and delivering individualized care.
Unattended and Unlocked Medication Cart Exposes Medications
Penalty
Summary
A deficiency was identified when a medication cart in the 100 Hall was found unlocked and unattended in the hallway, exposing its contents to unauthorized access. The cart contained over-the-counter (OTC) medications, prescription medications, syringes, more than 30 lancets, and over 100 pen needles, as well as inhalation solutions, inhalers, and topical creams. The cart was left unattended by an LVN who stated she was interrupted by a resident request during medication pass, resulting in the cart being left unlocked and unsupervised. Interviews with the LVN and the Interim DON confirmed that facility policy requires medication carts to be locked when not in use and under direct supervision, to prevent unauthorized access, especially by cognitively impaired residents. Review of the facility's Medication Management policy further supported this requirement, stating that medication carts must be locked when not in use and that keys are to be kept with authorized staff. The failure to secure the medication cart was observed directly by surveyors and acknowledged by staff.
Failure to Provide Physician-Ordered Pureed Diet to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered pureed diet due to dysphagia was served a mechanical soft lunch tray instead of the required pureed consistency. The resident's medical record indicated a history of difficulty swallowing, severe cognitive impairment, and a care plan specifying the need for a pureed diet to prevent choking and aspiration. Despite these documented needs, the resident was provided with the incorrect food texture during a meal service. The error originated in the kitchen, where the dietary aide, feeling rushed, misread the meal ticket and placed a mechanical soft plate on the tray instead of the pureed plate. The tray was then delivered to the resident's room by a CNA, who did not notice the inconsistency and began feeding the resident. The nurse was not present during the initial tray delivery and did not check the tray before feeding commenced. The CNA gave the resident one bite and attempted a second before the resident refused further intake by closing her lips. The mistake was identified when the nurse entered the room and recognized the resident was being fed the wrong diet. The tray was immediately removed, and the resident was assessed for any signs of aspiration or choking, with no adverse symptoms observed at that time. The incident was reported to supervisory staff, and the resident's physician and family were notified. The deficiency was attributed to failures in both dietary and nursing staff to verify the correct diet consistency before serving and feeding the resident.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for a resident, leading to the development of a stage 3 sacral pressure ulcer and an unstageable pressure injury on the right buttock. The resident, who was at risk for skin breakdown due to impaired mobility and incontinence, was not properly monitored or treated for skin issues. Despite the presence of redness on the resident's buttocks noted by a CNA, the LVN did not follow the facility's protocol to initiate adequate wound interventions or notify the appropriate personnel. The resident's care plan included specific instructions for pressure ulcer prevention and management, such as regular skin assessments and the use of barrier creams. However, the facility failed to ensure that comprehensive weekly skin assessments were completed, resulting in a delay in initiating wound care. The lack of documentation and communication among staff members contributed to the oversight, as the redness was not reported to the wound care nurse or the resident's physician in a timely manner. Interviews with staff revealed that there was a breakdown in communication and adherence to protocols. The treatment nurse was not informed of the redness until the wounds had progressed, and the floor nurses did not consistently perform or document the required skin assessments. The facility's failure to follow professional standards of practice placed the resident at risk of experiencing pain and possible infection from avoidable pressure wounds.
Failure to Provide Adequate Grooming Care for Resident
Penalty
Summary
The facility failed to provide adequate care and assistance for a resident who was unable to perform activities of daily living, specifically in maintaining good grooming. The resident, who had multiple medical conditions including dementia, hemiplegia, and functional quadriplegia, was found with a thick accumulation of a brown, flaky substance on her scalp and matted hair that required cutting. Additionally, her nails were not properly groomed, resulting in a dark brown/black substance accumulating underneath them. These issues were not documented in the resident's progress notes, and there was no indication that the resident refused care or that the facility staff attempted to address these grooming deficiencies. The resident's care plan indicated that she required substantial assistance with personal hygiene and was dependent on staff for various activities, including showering and hair care. Despite this, there was a lack of documentation and communication regarding the resident's grooming needs. Interviews with facility staff revealed that the resident's hair had been matted for an extended period, and there was no attempt to resolve the issue by cutting the hair or notifying the resident's responsible party (RP) or physician. The facility's policy on activities of daily living emphasized the importance of maintaining proper grooming and hygiene, yet these standards were not met in the resident's care. The failure to notify the resident's RP and physician about the grooming issues resulted in a delay in treatment and care. The resident's RP was unaware of the matted hair and scalp condition until the resident was admitted to an acute care hospital, where the RP had to cut the matted hair and attempt to clean the scalp. The facility's lack of communication and documentation regarding the resident's grooming needs placed the resident at risk for scalp itch, odors, infection, and undesirable haircuts, as noted in the report.
Wound Care Nurse Breaches Resident Privacy by Announcing Treatment in Hallway
Penalty
Summary
A deficiency occurred when a wound care nurse announced from the hallway, outside a resident's room, that she was about to perform wound care on the resident's sacrum. This announcement was made with the door half-open and within hearing range of others in the hallway. The nurse initially denied making the announcement but later acknowledged it, stating she was nervous and did not want to enter the room without the resident's permission. The resident, who is cognitively intact and fully dependent for care due to quadriplegia and other significant medical conditions, was not aware that his care had been announced in this manner but stated he would not want others to know about his personal medical issues. The facility's policy requires that residents be provided with both visual and auditory privacy during treatment and conversations. The administrator confirmed that announcing a resident's care from the hallway would be a dignity concern and could cause embarrassment. The incident was observed and confirmed during interviews with the nurse, the resident, and the administrator, and was found to be inconsistent with the facility's resident rights policy.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper wound care provided to a resident with a stage 4 pressure ulcer. During a wound treatment procedure, the Wound Care Nurse did not follow established protocols for hand hygiene and glove changes. Specifically, after removing the old dressing and cleansing the wound, the nurse did not change gloves before applying the new treatment and dressing, instead using the same gloves that had come into contact with the wound bed. Additionally, the nurse did not allow hand sanitizer to dry before donning gloves, which further compromised infection control practices. The resident involved was a male with multiple complex medical conditions, including quadriplegia, MRSA infection, and incontinence, and was totally dependent on staff for all activities of daily living. He had a documented stage 4 pressure ulcer on his sacrum, with ongoing wound management and regular assessments. The care plan and physician orders required specific infection control measures, including the use of personal protective equipment and proper hand hygiene during wound care procedures. Interviews with the Wound Care Nurse and the Nurse Consultant confirmed that the nurse did not follow facility policy or best practices for infection control during the wound care event. The nurse admitted to not changing gloves between wound cleansing and dressing application and acknowledged not allowing hand sanitizer to dry before gloving. The facility's wound care checklist and policy required glove changes and proper hand hygiene, which were not adhered to during the observed procedure.
Improper Food Storage in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. A 13.7-quart container of brown sugar was found unlabeled and left open to the air, which could lead to contamination. This observation was made during a kitchen inspection, where it was noted that the container was not sealed, allowing potential contaminants such as chemicals and pests to enter. The lack of proper labeling and sealing of the container was acknowledged by the staff, including the Dietary Manager and the Administrator, who both recognized the risk of contamination and the potential for residents to become ill as a result. Interviews with the staff revealed an understanding of the risks associated with improper food storage. The staff member interviewed on December 18, 2024, acknowledged that leaving the container open could lead to contamination, which could make residents sick. The Dietary Manager also confirmed that the brown sugar was not covered or labeled, which could result in contamination and illness among residents. The facility's Nutrition Policies and Procedures, dated June 2023, require that opened packages be tightly sealed and that containers holding food removed from their original packaging be labeled with the common name of the food, which was not followed in this instance.
Failure to Coordinate PASRR Assessments for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure proper coordination of assessments with the Pre-Admission Screening and Resident Review (PASRR) program for one resident, identified as Resident #104. The deficiency occurred because the facility did not correctly identify Resident #104 as having a mental illness in her PASRR Level 1 Screening. This oversight was significant given Resident #104's medical history, which included diagnoses of metabolic encephalopathy, depression, major depressive disorder, and anxiety disorder. Additionally, she was prescribed antidepressant medications, Mirtazapine and Sertraline, and had a BIMS score indicating moderate cognitive impairment. The MDS Coordinator, who had been working at the facility for six months, acknowledged the discrepancy in the PASRR screening and mentioned that the process involved verifying diagnoses with the physician and filling out form 1012 if discrepancies were found. However, the MDS Coordinator was unsure why Resident #104's PASRR was missed, noting that there was supposed to be another MDS Nurse and a Corporate MDS Nurse to assist in checking the accuracy of records. The Corporate MDS Nurse confirmed that the hospital issued the initial PASRR and that the facility was responsible for identifying positive PASRRs and ensuring residents received necessary psych services. The facility's PASRR Documentation Policy required all applicants to be evaluated for serious mental disorders and to receive appropriate services, which was not adhered to in this case.
Improper Garbage Disposal Due to Unsecured Dumpster Lid
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed with one of the two dumpsters used for garbage disposal. During an observation, it was noted that the lid of the dumpster on the left side was wide open. This observation was made in the dumpster area located at the back of the facility. Interviews with the facility's Cook and Dietary Manager confirmed that the staff is aware of the requirement to keep dumpster lids closed to prevent attracting pests such as bugs, flies, rodents, roaches, and raccoons. The Cook expressed concerns that if pests were attracted to the dumpster, they could potentially move towards the facility, posing a safety issue for residents. The facility's Nutrition Policies and Procedures, dated June 20, 2023, and the Food-Related Garbage and Rubbish Disposal policy, revised in April 2006, both emphasize the importance of keeping waste containers covered and dumpsters closed to prevent the transmission of disease and to avoid attracting pests. The policies also require that the area around dumpsters be kept clean and free of litter. Despite these policies, the failure to secure the dumpster lid was observed, indicating non-compliance with the facility's established procedures for waste disposal.
Failure to Verify G-Tube Placement and Administer Medications by Gravity
Penalty
Summary
The facility failed to ensure that a resident fed by enteral means received appropriate treatment and services to prevent complications of enteral feedings. Specifically, RN A did not verify the placement of the G-tube by aspirating stomach contents before administering water flushes and medications to Resident #85. Instead of allowing the flushes and medications to flow by gravity, RN A used a syringe plunger to administer them, which is against the recognized standards of practice. Resident #85, a male with a history of nontraumatic subarachnoid hemorrhage, dysphagia, aphasia, and cognitive communication deficit, was admitted to the facility with a gastrostomy tube for enteral nutrition. His care plan required enteral nutrition support to meet his energy, protein, and hydration needs, with specific instructions for water flushes and medication administration. However, during an observation, RN A failed to follow these instructions, potentially placing the resident at risk for adverse reactions and inadequate therapy. The Director of Nursing (DON) confirmed that RN A did not aspirate for residuals or administer medications by gravity, as required by the facility's policy and the Lippincott Nursing Procedures. The DON acknowledged the risks associated with not verifying tube placement and using a syringe plunger, which could lead to complications such as aspiration. The facility's policy mandates that licensed nurses administer medications by enteral tube using appropriate methods according to recognized standards of practice.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as evidenced by the lack of labeling and dating of the resident's oxygen tubing and improper connection of the oxygen humidifier. The resident, a cognitively intact male with a history of nontraumatic intracranial hemorrhage, HIV, hemiplegia, hemiparesis, and COPD, was observed with his oxygen humidifier connected to his roommate's side of the room. The resident expressed concerns about the oxygen tubing being pinched and the risk of disconnection due to its placement, which could lead to difficulty breathing and anxiety. Interviews with facility staff, including an LVN and the DON, revealed a lack of adherence to the facility's oxygen therapy policy, which requires weekly changes and proper labeling of oxygen equipment. The LVN, who had been at the facility for one month, was unaware of the reasons for the discrepancies in labeling and dating. The DON confirmed the expectation for weekly changes and acknowledged the risk of infection and nasal cavity dryness if the humidifier ran out of water. The facility's administrator also emphasized the importance of following orders and policies for oxygen therapy to prevent infection control issues.
Inaccurate MDS Assessments for Resident Behaviors
Penalty
Summary
The facility failed to ensure accurate assessments of residents' behaviors on their quarterly Minimum Data Set (MDS) assessments, specifically for two residents. Resident #1, a female with multiple diagnoses including schizophrenia and depression, was noted in nurse's notes to have refused care on several occasions, such as refusing a blood sugar fingerstick and becoming combative when staff attempted to provide a shower. Despite these documented behaviors, her MDS assessment inaccurately reflected no behavioral symptoms or rejection of care. Resident #2, also a female with a diagnosis of dementia and anxiety, was similarly misrepresented in her MDS assessment. Although nurse's notes documented instances of her refusing care, such as declining a lidocaine patch and refusing assistance with personal hygiene and bed linen changes, her MDS assessment indicated no behavioral symptoms or rejection of care. Interviews with staff, including the MDS Coordinator and Social Worker, revealed a lack of awareness and oversight in accurately coding these behaviors on the MDS. The inaccuracies in the MDS assessments for both residents could potentially place them at risk for not receiving appropriate care and services tailored to their needs. The Social Worker admitted to missing documentation of the residents' behaviors during the MDS review process, which contributed to the inaccurate coding. The facility's failure to accurately assess and document these behaviors highlights a deficiency in the assessment process, which is crucial for ensuring residents receive the necessary care and interventions.
Deficiency in Resident's ADL Care and Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. The resident, a female with multiple medical conditions including chronic obstructive pulmonary disease, hypertension, diabetes, and cognitive impairment, required substantial assistance with toileting, bathing, and grooming. Despite these needs, observations revealed that the resident's personal hygiene was neglected, as evidenced by long and dirty fingernails and matted hair. Interviews with staff members highlighted inconsistencies in the care provided to the resident. A Certified Nursing Assistant (CNA) responsible for the resident's care admitted to not completing the cleaning of the resident's hands and reported the issue of long nails to a nurse. However, the nails remained untrimmed, and the resident's hands were observed to be dirty. The CNA also mentioned that the resident sometimes refused care, which contributed to the lack of grooming. Additionally, a Licensed Vocational Nurse (LVN) acknowledged the absence of a hand roll for the resident, which was necessary for her contracted hand. Further interviews with the Director of Nursing (DON) and other staff members confirmed the oversight in maintaining the resident's hygiene. The DON recognized the need for nail trimming and hair care but noted that aides were not permitted to cut nails, leaving the responsibility to the podiatrist or nursing staff. The lack of coordination and follow-through in addressing the resident's grooming needs resulted in the deficiency observed by surveyors.
Failure to Address Hand Contracture in Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, specifically neglecting to implement interventions for a hand contracture. The resident, a female with multiple diagnoses including hemiplegia and severe cognitive impairment, was observed with a contracted right hand that lacked a hand roll, which is necessary to prevent further deterioration. The resident's nails were long, dirty, and pressed into the palm, indicating a lack of proper hygiene and care. Interviews with staff revealed that the resident's hand contracture was not being addressed adequately. A CNA responsible for the resident's care confirmed the absence of a hand roll and noted difficulties in maintaining the resident's hand hygiene. The CNA reported the issue of long nails to a nurse, but the problem persisted. An LVN acknowledged the need for a hand roll but was unaware of why it was not in place. The DON also recognized the need for nail trimming and the use of a hand roll, indicating a lapse in the facility's care protocols. The resident's care plan did not include interventions for the hand contracture, and the MDS Coordinator admitted that the care plan should have addressed range of motion issues. The facility's restorative nursing policies require assessment and implementation of a program to maintain or improve joint mobility, but these were not followed. The deficiency was identified when the resident was only picked up by therapy after the issue was brought to the facility's attention, highlighting a significant oversight in the resident's care management.
Failure to Maintain Sanitary Environment for Resident
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment for a resident, as evidenced by a strong smell of ammonia reported by the resident's family member. The family member discovered that the resident's underlay and nightgown were soaking wet with urine and left on the resident's wheelchair. This incident was reported on a weekend, and the family member had difficulty locating the weekend supervisor to address the issue immediately. The resident involved was an elderly woman with severe cognitive impairment, dementia, dysphagia, cellulitis, muscle wasting, and atrophy. She was dependent on staff for all activities of daily living (ADLs) and used a wheelchair. Her care plan included interventions for incontinence and skin protection, but the incident indicated a failure to adhere to these interventions, as the resident was left in an unsanitary condition. Interviews with staff revealed that a new aide, who was working for the first time after orientation, was responsible for the resident's care at the time of the incident. The aide reportedly forgot to remove the soiled linen from the resident's wheelchair. The weekend supervisor and other staff members were involved in addressing the family's concerns, but there was no clear determination of who was responsible for the oversight. The facility's grievance system recorded the incident, but there was no indication of immediate corrective actions or re-education for the staff involved.
Inadequate Pressure Ulcer Care Due to Supply Shortages and Protocol Failures
Penalty
Summary
The facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Specifically, Resident #3 did not receive adequate treatment for a stage 4 pressure ulcer on the right buttock, as the facility did not follow the physician's orders to apply Bactroban and Alginate. Additionally, the Assistant Director of Nursing (ADON) did not perform proper hand hygiene during wound care, increasing the risk of infection. The facility also lacked the necessary supplies, leading the ADON to make improvised dressings using gauze and tape instead of the prescribed materials. Resident #4 also experienced inadequate wound care due to the facility's failure to provide the necessary supplies. The resident's right hip stage 3 pressure ulcer was not treated with the appropriate dressings, and the ADON had to substitute with makeshift materials. Furthermore, a CNA did not perform proper perineal care or hand hygiene, which could contribute to the resident's risk of infection. The facility's central supply issues were highlighted by multiple staff members, who reported that the Administrator had restricted orders due to budget constraints, leading to a shortage of essential wound care supplies. Interviews with staff and observations revealed that the facility's wound care processes were compromised due to the lack of supplies and failure to follow physician orders. The Wound Care Nurse and other staff members confirmed that they had been using alternative materials for wound care due to the unavailability of the prescribed dressings. The facility's failure to maintain adequate supplies and adhere to proper wound care protocols placed residents at risk for worsening pressure ulcers and infections.
Failure to Provide Proper Incontinence and Catheter Care
Penalty
Summary
The facility failed to ensure proper care for residents who were incontinent of bladder, leading to increased risk of urinary tract infections. Specifically, CNA A did not practice proper technique while providing incontinence care for a resident. During the care, CNA A did not spread the resident's labia to thoroughly clean the area and the urinary meatus. Additionally, CNA A failed to perform hand hygiene while changing gloves, which could result in cross-contamination. CNA A admitted to not recalling any competency checks for incontinence care at the time of hire and missing the last infection control training due to being out with COVID-19. Another deficiency was observed when ADON A placed a catheter bag on the bed while performing wound care on the same resident. This action posed a risk of contamination and backflow of urine. The ADON acknowledged that the catheter bag should have been placed below the bed to prevent these risks. For another resident, the facility failed to ensure the use of a catheter strap, which is essential to keep the catheter from dislodging. The resident reported that the strap had been missing for a week, and the nurses had not replaced it. The absence of the strap could lead to urethral trauma and increased risk of infection. The ADON confirmed that it was the nurse's responsibility to replace the strap and acknowledged the potential risks associated with its absence.
Infection Control Deficiencies in Wound and Incontinence Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to deficiencies in the care of two residents and the actions of two staff members. Specifically, the Assistant Director of Nursing (ADON A) did not perform proper hand hygiene when moving from a dirty to clean site while performing wound care on a resident with multiple stage 4 pressure ulcers. During the wound care, ADON A failed to wash or sanitize her hands after removing soiled gloves and before applying clean dressings, which could lead to cross-contamination and infection. This was observed during a wound care session where the ADON handled the resident's wounds without adhering to proper infection control protocols, such as washing hands between glove changes and after touching contaminated objects like scissors and the foley catheter. The ADON acknowledged the lapse in infection control during an interview, admitting that her actions placed the resident at risk for infections. Another deficiency was observed with a Certified Nursing Assistant (CNA A) who failed to properly change gloves and wash or sanitize her hands when providing incontinence care to a resident with dementia and a stage 3 pressure ulcer. CNA A did not spread the resident's labia to thoroughly clean the area and proceeded to touch clean items with soiled gloves. She also applied Vaseline to the resident's buttocks with soiled gloves and then touched the resident's clean shirt, brief, sheet, and blanket without performing hand hygiene. In an interview, CNA A admitted to not following proper infection control procedures and acknowledged that her actions could result in cross-contamination and infections. She also mentioned that she had not received recent training on proper incontinence care at the facility. The facility's infection preventionist, ADON B, confirmed that staff are expected to follow standard infection control techniques, including handwashing before treatments, between glove changes, and after moving from dirty to clean sites. However, it was noted that CNA A had missed the last infection control training due to being out with COVID. The facility's policies and procedures on infection prevention and control, as well as hand hygiene, were reviewed and found to be in place, but not adequately followed by the staff involved in these incidents.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #3, who has multiple medical conditions including quadriplegia, stage 4 pressure ulcers, and type 2 diabetes mellitus with hyperglycemia. The resident's care plan, which was supposed to ensure proper wound care, was not followed as the facility did not administer Bactroban and Calcium Alginate as ordered by the Wound Care Doctor on 01/11/2024. This oversight was observed during a wound care session on 01/14/2024, where the ADON did not apply the prescribed medications to the resident's wounds, despite the presence of signs of infection in the right buttock wound. The ADON also failed to maintain proper hand hygiene during the procedure, which could further compromise the resident's health. The ADON admitted to not being aware of the new orders due to a lapse in updating the electronic medical record (EMR) with the latest wound care doctor's recommendations. The Wound Care Doctor confirmed that Bactroban was ordered prophylactically due to the resident's incontinence and previous concerns about wound infections. The facility's policy on physician orders was not followed, leading to the resident not receiving the necessary medication and potentially delaying essential medical treatment.
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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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