The Hillcrest Of North Dallas
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 18648 Hillcrest Rd, Dallas, Texas 75252
- CMS Provider Number
- 676315
- Inspections on file
- 60
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at The Hillcrest Of North Dallas during CMS and state inspections, most recent first.
Surveyors found that the maintenance office was left unlocked and unattended, with hazardous chemicals such as a ZEP spray bottle and an All Purpose Leak Detector accessible. Both the Maintenance Director and administrator confirmed the office should have been locked to prevent resident access to these substances, in accordance with facility policy.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with an indwelling urinary catheter and intact cognition was observed in a public area without a privacy cover on his urinary drainage bag. Staff interviews confirmed that the lack of a privacy cover was a dignity issue and that staff were expected to ensure privacy covers were used for residents with urinary drainage bags.
A resident's care plan was found to be incomplete, missing measurable timetables and specific actions to address all identified needs. Review of records and observations confirmed that the care plan did not provide comprehensive or actionable guidance for staff.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
A resident with multiple medical conditions and an identified need for dental extractions did not receive timely dental care or follow-up after an assessment and physician referral. The care plan lacked documentation of dental needs, and staff interviews confirmed that required referrals and coordination for dental services were not completed as per facility policy.
Three residents did not receive their prescribed pain medications as ordered due to the facility's failure to ensure timely reordering and availability of narcotics, resulting in multiple missed doses. Staff were unable to obtain medications from the emergency kit in some cases due to lack of updated orders, and alternative pain relief was provided until the correct medications arrived. Interviews indicated issues with medication reordering processes, pharmacy communication, and staff training during a period of management turnover.
A resident with multiple pain-related diagnoses received an extra dose of Pregabalin when an LVN, after being given the medication cart key by a Medication Aide, failed to verify the MAR and administered an additional dose. The LVN then falsely documented the dose as wasted, and the Medication Aide signed the waste form without witnessing the event, resulting in inaccurate medication records and a breach of medication administration protocols.
A resident with complex pain management needs received an extra dose of Pregabalin when an LVN administered the medication without verifying the MAR or narcotic log, shortly after a Medication Aide had already given the scheduled dose. The LVN falsely documented the dose as wasted, and the Medication Aide signed the waste form without witnessing the event, resulting in a significant medication error and improper documentation.
A resident with recent knee surgery and ongoing pain and mobility issues did not have a comprehensive, person-centered care plan addressing pain management or physical therapy. Despite receiving scheduled pain medications and having therapy orders, the care plan lacked measurable objectives and updates for these needs. Staff interviews confirmed the resident's dissatisfaction with pain control and lack of therapy, and the care plan did not reflect these ongoing concerns.
A resident with multiple medical and mental health conditions was discharged without sufficient preparation or documentation, including missing discharge MDS, lack of a physician's discharge order, and no follow-up after the resident chose to be transported to a motel instead of a shelter. The facility did not ensure proper discharge planning or post-discharge contact, as required by policy.
A facility failed to change a resident's tracheostomy tubing within the required seven-day period, as observed with tubing dated 11 days prior. The resident, who was severely cognitively impaired, required weekly changes of tracheostomy equipment to prevent infection. Interviews with the LVN and ADON revealed lapses in adherence to the facility's policy and physician's orders, with the usual audit process not conducted due to the ADON's recent vacation. The DON confirmed the expectation for nurses to check equipment dates each shift.
A resident with a history of lung cancer and paraplegia was not provided with a suitable mattress to alleviate pain and prevent pressure ulcers. Initially given a low air loss (LAL) mattress, the resident was later switched to a pressure relieving mattress, causing discomfort and back pain. Despite the resident's medical history and risk of pressure ulcers, the facility did not document the mattress change or provide a LAL mattress until after the resident's complaints.
A resident with severe cognitive impairment and a history of stroke did not receive appropriate treatment to maintain range of motion, leading to a decline in condition. Despite a care plan for using a resting hand splint and palmar guard, these were not consistently applied, resulting in a wound on the resident's hand. Staff interviews revealed inconsistencies in care and documentation, contributing to the resident's decline.
The facility failed to administer medications on time for two residents, with late administration of Acidophilus Lactobacillus and Gabapentin. Both residents, who were cognitively intact, experienced delays in receiving their medications as ordered. Interviews revealed that staff were unaware of complaints about late medication passes, and documentation of these delays was lacking.
A resident with multiple medical conditions had her bed bath refusals documented late, contrary to the facility's policy. The refusals were recorded on a single day after an investigation began, despite being communicated to a nurse earlier. Staff interviews revealed a lack of timely documentation, which could impact resident care.
A resident with multiple health conditions did not receive scheduled bed baths consistently, leading to a deficiency in personal hygiene care. Despite being cognitively intact and expressing a preference for bed baths, the resident reported not receiving proper care for three weeks. Staff interviews revealed issues with short staffing and inadequate documentation of care refusals, contributing to the deficiency.
The facility failed to protect two residents from abuse. One resident reported being verbally and physically abused by the Assistant Dietary Manager, but the facility's investigation found no witnesses to corroborate the abuse. Another resident, with Alzheimer's and impaired cognition, was not protected from sexual abuse, as she was found in bed with another resident who had unmonitored access to her. These failures placed residents at risk for serious harm.
A facility failed to implement its abuse prevention policies, resulting in two residents being exposed to abuse. One resident was not protected from sexual abuse when another resident was found in her bed, and the facility did not follow procedures for criminal sexual abuse. Another resident was not safeguarded from verbal and physical abuse by a staff member, and the facility did not conduct a thorough investigation. These failures placed all residents at risk for harm.
The facility failed to thoroughly investigate abuse allegations involving two residents, leading to Immediate Jeopardy. One resident, cognitively intact, claimed physical assault by the Assistant Dietary Manager, but the investigation was unconfirmed due to lack of witnesses. The facility did not complete necessary documentation or assessments. The second resident, with Alzheimer's, was involved in an incident not thoroughly investigated. The facility's failure to adhere to abuse prevention protocols resulted in significant deficiencies.
A facility failed to update a resident's care plan after two alleged sexual abuse incidents, one involving a staff member and another involving a male resident. The resident, with Alzheimer's and moderately impaired cognition, was not provided with individualized interventions or objectives in her care plan to prevent further victimization. Staff interviews revealed confusion over responsibility for care plan updates, and the facility's policy on comprehensive care plans was not presented.
A facility failed to maintain proper infection control when an ADON did not perform hand hygiene or change gloves appropriately during wound care for a resident with multiple health conditions. Despite being aware of the protocols, the ADON neglected to follow them, potentially increasing the risk of infection transmission.
A facility failed to provide adequate pharmaceutical services, leading to incorrect medication administration and documentation errors. A resident did not receive the correct pain medication, and staff failed to document the administration and refusal of controlled substances properly. Additionally, medications for a discharged resident were not removed from the cart, risking medication errors and drug diversion.
A resident with a care plan requiring a Hoyer lift and two-person assistance was improperly transferred by a PT student alone, resulting in a fall and fracture. The PT student, on her first LTC rotation, attempted the transfer without necessary equipment or assistance, despite knowing the resident's needs. The incident led to hospitalization and surgery for the resident.
A resident with urinary incontinence and an external catheter system was not provided with proper care and management at the facility. The facility lacked physician's orders for the catheter system and did not implement a urinary toileting program. Observations showed poor management of the PureWick system, leading to foul odors and skin irritation. Staff interviews revealed a lack of knowledge and training in managing the system, and the DON acknowledged the absence of necessary orders and procedures.
The facility failed to update and notify residents of menu changes, resulting in meals differing from the posted menu. A resident with severe cognitive impairment expressed dissatisfaction with the food and was unaware of the option to request alternate meals. Staff confirmed that menus were not distributed, and meal choices depended on kitchen availability. The Dietary Supervisor admitted the menu change was due to a vendor issue, and the menu was not updated to reflect this change.
The facility failed to maintain accurate medical records for two residents, leading to potential risks in their care. One resident was incorrectly prescribed Pimozide for psychosis, despite no history of the condition. Another resident's weekly lab orders were not updated to reflect discontinuation, resulting in infrequent lab work. These documentation errors could lead to inappropriate treatment.
A nurse inserted a Foley catheter into a resident without a physician's order, contrary to facility policy. The resident, who had functional bladder incontinence and no diagnosis of urinary retention, complained of difficulty urinating. The nurse proceeded with the catheter insertion after failing to reach the primary care provider, which was acknowledged as inappropriate by the ADON and DON.
A resident was found with medications, Unisom and Ketoconazole, on her bedside table, despite not being authorized to self-administer. The facility staff were unaware of the medications, which were brought by the resident's sister. The facility's policy on medication storage was not followed, posing a risk of overdose or interactions.
The facility failed to obtain immediate physician orders for wound care for a resident admitted with a surgical wound. The orders were not entered until five days after admission, despite hospital discharge instructions. This lapse was due to a failure in the facility's system for reviewing new admission records.
A resident with a surgical wound on her right foot did not receive the prescribed wound vac treatment on two specific dates due to a lack of communication and oversight in entering and following wound care orders. The facility did not have the necessary equipment upon the resident's admission, and the interdisciplinary team failed to review the new admission records properly.
The facility failed to transcribe wound care orders and document the administration of an IV antibiotic for a resident with peripheral vascular disease and osteomyelitis. The resident's wound care orders were not entered into the electronic health record until several days after admission, and the administration of Vancomycin was not documented on two specific dates.
The facility failed to treat two residents with respect and dignity during meal assistance. An LVN was observed standing between two residents while feeding them, rather than sitting and providing individualized attention. Interviews with staff confirmed awareness of the requirement to sit while assisting residents with eating to maintain their dignity.
A CNA transferred a resident using a mechanical lift without assistance from another staff member, contrary to the facility's policy and training. The resident, who required substantial assistance for transfers but did not have a mechanical lift indicated in her care plan, was placed at risk for accidents and injuries.
Unlocked Maintenance Office with Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that the maintenance office, which contained hazardous chemicals, was kept locked when unattended. On two separate observations, the maintenance office door at the end of the 300 hall was found propped open with no staff present. Inside the office, a spray bottle labeled ZEP containing a pink liquid and a container labeled All Purpose Leak Detector were accessible. Both products had warning labels indicating they should be kept out of reach of children due to potential hazards. Interviews with the Maintenance Director and the administrator confirmed that the office should have been locked when unoccupied. The Maintenance Director acknowledged that he must have forgotten to lock the door and recognized the risk of residents accessing hazardous materials. The facility's policy required that cleaning supplies and similar substances be stored securely and as instructed on product labels, which was not followed in this instance.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Provide Privacy Cover for Urinary Drainage Bag
Penalty
Summary
A deficiency was identified when a male resident with an indwelling urinary catheter and a history of neurogenic bladder, quadriplegia, hypertension, type 2 diabetes, and schizophrenia was observed in a public area of the facility without a privacy cover on his urinary drainage bag. The resident, who was cognitively intact and dependent on staff for toileting, was seen in his wheelchair in the lobby by the dining room entrance with the drainage bag exposed. The resident did not comment on the lack of a privacy cover during the observation. Staff interviews confirmed that the urinary drainage bag should have had a privacy cover in place to maintain the resident's dignity. Both a licensed vocational nurse and the Director of Nursing acknowledged that the absence of a privacy cover was a dignity issue and that staff were expected to ensure privacy covers were used for residents with urinary drainage bags. The facility's policy on resident rights also emphasized the importance of informing residents of their rights during their stay.
Incomplete Care Plan Lacking Measurable Actions
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 requirements. This deficiency was based on observations and review of the resident's records, which showed that the care plan did not comprehensively cover all identified needs or include clear, measurable steps for staff to follow.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents, and that supervision was insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Coordinate and Provide Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining routine and emergency dental care after a dental assessment indicated the need for seven teeth to be extracted due to broken root tips and an abscess. Despite the assessment and a physician's referral for dental services, the resident's care plan did not address dental needs, and there was no evidence of follow-up or coordination for the required dental procedures. The resident reported ongoing issues with broken and missing teeth, as well as an infection, and stated that he had not received information about follow-up exams or treatment. He had communicated his dental concerns to both the physician and the social worker, but no action was documented. Interviews with facility staff, including the Regional Social Services Consultant, Administrator, and DON, confirmed that the responsibility for dental referrals and follow-ups rested with the social worker. However, the staff acknowledged that the resident had not been seen for the necessary dental care since the initial assessment. The facility's policy required the Director of Social Services to coordinate referrals for outside services, but this process was not followed for the resident in question, resulting in a lack of timely dental care.
Failure to Ensure Timely Administration of Pain Medications Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of routine and emergency drugs for three residents. In each case, residents did not receive their prescribed pain medications as ordered by their physicians, resulting in missed doses. For one resident with fibromyalgia and chronic pain syndrome, three doses of Hydrocodone-Acetaminophen were missed in a single day due to the medication not being available. The nurse was unable to obtain the medication from the emergency kit because the pharmacy required an updated order, and the resident was given Tylenol as an alternative until the medication arrived later that day. Another resident with a history of fractures did not receive two scheduled doses of Oxycodone HCL because the medication was not available at the facility. The pharmacy was contacted and reported that the medication would be delivered in the evening, and the resident received an alternative pain medication in the interim. The resident was away from the facility for several other scheduled doses that day, and the first dose of the new supply was administered in the evening. A third resident with multiple diagnoses, including chronic pain and neuropathic pain, missed two doses of Hydrocodone-Acetaminophen because the facility ran out of the medication. The emergency kit was used to provide some doses, but the regular supply was not available until later. Interviews with staff revealed issues with timely reordering of medications, communication lapses with the pharmacy, and confusion regarding the process for obtaining emergency medications. The facility did not provide a policy regarding the reordering of narcotic medications when requested.
Failure to Administer and Document Medications per Physician Orders and Facility Policy
Penalty
Summary
A deficiency occurred when a resident received an extra dose of Pregabalin (Lyrica) due to a breakdown in medication administration procedures. The resident, who had a history of narcotic dependence, osteoarthritis, joint replacement, spinal stenosis, neuropathy, and recent knee surgery, was prescribed Pregabalin 100 mg to be administered three times daily. On the day of the incident, a Medication Aide administered the scheduled dose and documented it appropriately. However, during the Medication Aide's lunch break, an LVN, who had been given the medication cart key, administered an additional dose of Pregabalin to the same resident without verifying the Medication Administration Record (MAR) or the Narcotic Count Sheet. The LVN subsequently filled out a medication waste form, indicating that the medication was wasted when, in fact, it had been administered to the resident. The Medication Aide signed the waste form without witnessing the medication being wasted, as required by facility policy. This misdocumentation was discovered after the resident reported receiving two doses of the same medication within a short time frame and provided video evidence from his room camera. Interviews confirmed that the LVN did not follow the required checks and that the Medication Aide signed documentation without proper verification. The facility's policy required that medications be administered according to physician orders, with proper documentation and verification, including the presence of two nurses when wasting medication. The failure to follow these procedures resulted in the resident receiving an unscheduled extra dose of medication and inaccurate documentation of medication handling. The incident was confirmed through interviews with the resident, staff, and review of video footage and records.
Failure to Prevent Significant Medication Error and Inaccurate Medication Waste Documentation
Penalty
Summary
A significant medication error occurred when a resident with a history of narcotic dependence, osteoarthritis, joint replacement, spinal stenosis, neuropathy, and post-surgical pain received an extra dose of Pregabalin (Lyrica) within a short time frame. The resident was cognitively intact and on a scheduled pain regimen, including PRN pain medications. On the day of the incident, a Medication Aide administered the resident's prescribed dose of Pregabalin and documented it appropriately. Shortly after, during the Medication Aide's lunch break, an LVN, who had been given the medication cart key, administered an additional dose of Pregabalin to the same resident without verifying the Medication Administration Record (MAR) or the Narcotic Count Sheet. The LVN subsequently filled out a medication waste form, indicating that the medication was wasted, even though it had been administered to the resident. The Medication Aide, upon returning from lunch, signed the waste form without witnessing the medication being wasted and without clarifying what she was signing. This resulted in inaccurate documentation and a failure to follow the facility's policy, which requires two nurses to witness and sign for wasted medications. The incident was discovered after the resident reported receiving two doses of the same medication within a short period and provided video evidence from his room to facility management. Interviews with staff confirmed that the LVN did not check the MAR or narcotic log before administering the additional dose and that the Medication Aide signed the waste form without proper verification. The facility's policy on medication administration and waste was not followed, leading to the resident receiving an extra dose of a controlled medication and improper documentation of medication handling.
Failure to Develop and Implement Comprehensive Care Plan for Pain and Therapy Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical and rehabilitation needs. The resident, a cognitively intact male with a history of hypertension, spinal stenosis, low back pain, and recent left total knee arthroplasty, was readmitted to the facility following surgery. Despite orders for scheduled pain medications and physical therapy, the care plan did not include specific, measurable objectives or timeframes for pain management or physical therapy interventions. The care plan also lacked updates to reflect the resident's ongoing pain and therapy needs after his readmission and subsequent hospitalizations. Observations and interviews revealed that the resident expressed dissatisfaction with his pain management, stating that his requests for increased pain medication were not met and that he had not received physical therapy since returning from the hospital. Nursing staff confirmed the resident's concerns about pain management and were unsure if pain or therapy needs were addressed in the care plan. The Director of Therapy indicated that therapy services had been interrupted by insurance issues and repeated hospitalizations, but there was no evidence that these changes were reflected in the care plan. The facility's policy requires the interdisciplinary team to develop a baseline and comprehensive care plan within specified timeframes, including measurable objectives and updates based on changes in the resident's condition. However, the care plan for this resident did not include a focus on pain management or physical therapy, nor did it document person-centered interventions for these needs. This omission was confirmed by the Administrator and Regional Nurse Consultant, who acknowledged that pain and therapy were not properly addressed in the care plan, despite the resident's ongoing needs and multiple interactions with pain management and therapy providers.
Failure to Provide and Document Safe Discharge Preparation
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a safe and orderly discharge of a male resident with multiple diagnoses, including cerebral ischemia, generalized anxiety disorder, hypertensive urgency, lack of coordination, and cognitive communication deficit. The resident was admitted to the facility and later discharged, but the records showed that key sections of the Minimum Data Set (MDS) assessment related to discharge were left blank, and a discharge MDS was not completed. The care plan indicated the resident's wish to return home and outlined steps for discharge planning, but there was no evidence of a physician's discharge order or comprehensive discharge planning documentation. The resident received a 30-day discharge notice due to failure to pay, and while the facility staff made referrals to other facilities, the resident refused these placements. On the day of discharge, the resident requested to be taken to a motel instead of a homeless shelter, and the facility van driver transported him to the motel, assisted with his belongings, and notified the administrator of the location. However, there was no follow-up by the facility to check on the resident's wellbeing or safety after discharge, and the resident's contact information was not documented for follow-up. Progress notes and interviews confirmed that the facility did not attempt to contact the resident post-discharge. Facility policy required discharge planning to ensure safe and appropriate transitions, including physician orders and communication with continuing care providers. Despite this, the facility did not complete the required discharge documentation, did not ensure a physician's order for discharge, and did not follow up with the resident after he left the facility. These actions and omissions resulted in a lack of documented preparation and orientation for the resident's discharge, as required by policy and regulation.
Failure to Change Tracheostomy Tubing Weekly
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for a resident, leading to a deficiency in infection control practices. The resident, who had a tracheostomy and required weekly changes of tracheostomy tubing, was observed with tubing dated 11 days prior, indicating it had not been changed within the required seven-day period. The resident, who was severely cognitively impaired and dependent on staff for care, was unable to communicate effectively about their care needs. The facility's records indicated that the tracheostomy care was supposed to be performed weekly on Sunday nights by the night shift nurse, but this was not completed as required. Interviews with the nursing staff, including the LVN responsible for the resident's care and the ADON, revealed a lack of adherence to the facility's policy and physician's orders regarding the timely change of tracheostomy equipment. The LVN admitted to not noticing the date on the tubing and failing to change it, while the ADON acknowledged that the usual audit process to ensure compliance was not conducted due to her recent vacation. The DON confirmed the expectation that all nurses should check the equipment dates each shift to prevent infection risks. The facility's policy required weekly changes of all oxygen-related equipment, which was not followed, leading to potential cross-contamination and infection risks for the resident.
Failure to Provide Appropriate Mattress for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as Resident #01, by not providing an appropriate mattress to alleviate pain associated with his medical conditions. Resident #01, a male with a history of lung cancer, paraplegia, and a previous stage 3 pressure injury, was initially provided with a low air loss (LAL) mattress upon admission to the facility. However, after being transferred to long-term care and changing rooms, the resident was given a pressure relieving mattress instead, which was firm and caused discomfort. The resident's medical records indicated a need for a LAL mattress due to his risk of developing pressure ulcers and his history of a stage 3 pressure injury. Despite this, there was no documentation of the mattress change in the resident's progress notes, and no orders for a LAL mattress were found. Interviews with the resident revealed that he experienced back pain and discomfort on the new mattress and had communicated his need for the previous mattress to various staff members, including the Director of Nursing (DON) and the Administrator. The DON and Administrator acknowledged the mattress change but stated that the resident did not meet the facility's criteria for a LAL mattress. The Administrator mentioned that the LAL mattress was reassigned to another resident, and a spare LAL mattress was eventually provided to Resident #01 after discussions. The facility's policy on support surfaces indicated that LAL mattresses are appropriate for residents with stage III or IV pressure ulcers, which aligns with the resident's previous condition, yet this was not initially adhered to, leading to the deficiency.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, resulting in a decline in the resident's condition. The resident, a female with severe cognitive impairment and a history of stroke, hypertension, diabetes mellitus, and aphasia, was dependent on staff for all activities of daily living. Despite having a care plan that included the use of a resting hand splint and a palmar guard, these interventions were not consistently implemented after the resident was discharged from occupational therapy. Observations and interviews revealed that the resident's left hand was drawn into a fist, with a wound in the center of the palm, and no splints or hand rolls were in place. The wound was described as bright red and smaller than a dime, with a decomposing smell noted by a family member. The family member also reported that the resident's nails were long and had caused the wound by digging into the skin. Despite previous requests to trim the resident's nails, the facility had not consistently done so, leading to further complications. Interviews with staff indicated a lack of clarity and consistency in the application of the resident's splint and palmar guard. Some staff members were unaware of the specific requirements for the resident's care, and there was a failure to document the application of splints and guards. The facility's policy required restorative nursing care to be provided by CNAs, with oversight by nurses, but this was not effectively carried out, contributing to the resident's decline in range of motion and the development of a wound.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, as evidenced by the inaccurate administration of medications. Resident #1, a cognitively intact female with multiple diagnoses including acute respiratory failure and type 2 diabetes, did not receive her Acidophilus Lactobacillus Oral Capsule every 12 hours as ordered. The medication administration audit report showed that the medication was given late on several occasions, with no documentation in the progress notes regarding these late passes. Similarly, Resident #2, a cognitively intact male with diagnoses such as type 2 diabetes and polyneuropathy, did not receive his Gabapentin every 12 hours as ordered. The medication administration audit report indicated that the medication was administered late on multiple dates, and there was no documentation in the progress notes about these late administrations. Resident #2 expressed concerns about the timeliness of his medication administration, noting that it was often delayed unless specific nurses were on duty. Interviews with facility staff, including the ADON, DON, and Administrator, revealed a lack of awareness regarding complaints about late medication administration. The facility's policy allows for medications to be administered within one hour of the scheduled time, but the documentation of late passes was not consistently completed. The facility's in-service training emphasized the importance of timely medication administration and documentation, yet these standards were not met in the cases of Residents #1 and #2.
Failure to Document Bed Bath Refusals Timely
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in documenting bed bath refusals for a resident. The resident, a cognitively intact female with multiple medical conditions including acute respiratory failure, cellulitis, type 2 diabetes, and hemiplegia, was scheduled for baths three times a week. However, her refusals were not documented on the same day, leading to late entries in her progress notes. The late documentation was identified during an investigation, with all refusals being recorded on a single day after the investigation began. Interviews with staff revealed that the caregiver responsible for the resident's care had not provided a bed bath in two weeks and was unsure if other staff had done so. The caregiver mentioned that refusals were communicated to a nurse, who was responsible for documenting them, but this process was not followed in a timely manner. The facility's policy required documentation to be completed by the end of the assigned shift, but this was not adhered to, as evidenced by the late entries. The LVN involved admitted to missing the documentation and only realized the oversight during the investigation. The DON and ADON acknowledged the importance of timely documentation and the potential impact on resident care, but were unsure how the oversight occurred. The facility had initiated in-services to address the issue, emphasizing the need for timely documentation.
Failure to Provide Scheduled Bed Baths and Document Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required help with personal hygiene. The resident, a cognitively intact female with multiple health conditions including acute respiratory failure, cellulitis, type 2 diabetes, and hemiplegia, was scheduled to receive bed baths on a Monday, Wednesday, and Friday schedule. However, records and interviews revealed that the resident did not receive these scheduled bed baths consistently, and there were discrepancies in the documentation of her care. The resident reported not having received a proper bed bath in three weeks and expressed dissatisfaction with the care provided, stating that she had not refused any showers or bed baths. She mentioned that staff often did not return to provide the care she requested if she asked them to come back later. The resident also noted that she had to rely on her son to help with her personal hygiene during his visits. Interviews with staff members indicated that the resident's care was affected by short staffing, and there were inconsistencies in documenting refusals of care. The facility's documentation practices were found to be inadequate, with late entries made by a Licensed Vocational Nurse (LVN) regarding the resident's refusals of care. The Director of Nursing (DON) and the Administrator acknowledged the importance of timely documentation and the risks associated with missed care, such as infection and impact on the resident's mental health. Despite the facility's policy requiring timely documentation and follow-up on refusals, these procedures were not consistently followed, leading to the deficiency in care for the resident.
Facility Fails to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a deficiency. Resident #1, a cognitively intact male with a history of stroke and heart failure, reported being verbally and physically abused by the Assistant Dietary Manager. The incident involved a verbal altercation over meal portions, during which Resident #1 claimed the Assistant Dietary Manager hit him in the chest, threw his walker, and grabbed him by the throat. Despite the resident's claims and subsequent hospital visit for injuries, the facility's investigation found no witnesses to corroborate the abuse, and the Assistant Dietary Manager was allowed to return to work. Resident #2, a female with Alzheimer's Disease and moderately impaired cognition, was not protected from sexual abuse. She was found in bed with another resident, Resident #3, who was on top of her. Resident #2 was unable to give consent for sexual activity, and the facility failed to prevent Resident #3 from having unmonitored access to her, despite her history as a prior victim of abuse. This lack of supervision and protection led to a serious breach of resident safety. The facility's inaction in both cases placed residents at risk for serious harm. The failure to adequately investigate and address the allegations of abuse, as well as the lack of proper monitoring and protection for vulnerable residents, highlighted significant deficiencies in the facility's ability to ensure resident safety and prevent abuse.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically failing to protect two residents from abuse. One resident was not safeguarded from sexual abuse when another resident was found in her bed. The facility did not initiate criminal sexual abuse procedures despite the resident's lack of decision-making capacity to consent to a sexual act. Law enforcement was not contacted for further direction, and the resident was not sent to the hospital for a Sexual Assault Nurse Examination (SANE). Additionally, the facility did not follow its policy to ensure another resident was free from verbal and physical abuse by the Assistant Dietary Manager. The facility failed to conduct a thorough investigation into this resident's allegation of abuse. These failures were identified as Immediate Jeopardy, indicating a severe risk to resident safety, although the Immediate Jeopardy was later removed, the facility remained out of compliance due to ongoing monitoring of their Plan of Removal. The report highlights that these deficiencies could place all residents at risk for victimization, abuse, and psychosocial harm. The facility's policies, such as the Abuse Prevention and Prohibition Program, were not effectively implemented, as evidenced by the lack of immediate notification to law enforcement and the absence of medical treatment and emotional support for the affected residents. The facility's investigation into the incidents was inadequate, with no substantial findings or appropriate interventions to prevent future occurrences.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, leading to an Immediate Jeopardy situation. For the first resident, who was cognitively intact and had a history of making false allegations, the facility did not conduct a comprehensive investigation into an incident where the resident claimed to have been physically assaulted by the Assistant Dietary Manager. Despite the resident's claims of being hit and having his walker thrown, the facility's investigation was deemed unconfirmed due to a lack of witnesses corroborating the resident's account. The facility did not complete an incident report, a resident assessment, or a trauma assessment on the day of the incident, and there was no police report available. The second resident, who had Alzheimer's Disease and a moderately impaired cognition, was also involved in an incident that was not thoroughly investigated. The report does not provide specific details about the nature of the incident involving this resident, but it indicates that the facility failed to ensure a comprehensive investigation was conducted. This lack of thorough investigation placed residents at risk for serious injuries and harm due to their allegations not being adequately addressed. The facility's policy on abuse prevention and prohibition requires prompt and thorough investigations of reports of resident abuse, mistreatment, neglect, or injuries of unknown sources. However, the facility did not adhere to these protocols, as evidenced by the incomplete investigations and lack of proper documentation and assessments following the incidents. The failure to follow these procedures resulted in the identification of Immediate Jeopardy, highlighting significant deficiencies in the facility's handling of abuse allegations.
Failure to Update Care Plan After Alleged Abuse Incidents
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for two residents, which included measurable objectives and time frames to meet their medical, nursing, and mental needs. Specifically, the care plan for a resident did not include individualized interventions and objectives after the resident was involved in two separate alleged sexual abuse incidents. The first incident involved a male staff member, and the second involved another male resident. The facility did not update the care plan to reflect these incidents or implement any measurable objectives or interventions to protect the resident from repeated victimization. The resident in question was a female with Alzheimer's Disease, age-related physical debility, and alcohol abuse, with a BIMS score indicating moderately impaired cognition. The resident was involved in an incident with a male resident, where staff witnessed the male resident in a compromising position in the resident's room. Despite the resident's inability to consent, the facility did not substantiate the findings of the incident, and no law enforcement or hospital examination was conducted. The care plan was not updated to include interventions to prevent further incidents. Interviews with facility staff revealed a lack of clarity and responsibility regarding updating the resident's care plan. The MDS Nurse, DON, and Administrator all indicated that care plans should be personalized and updated by an interdisciplinary team, yet the resident's care plan remained unchanged after the incidents. The facility's policy on comprehensive care plans was not presented, and the staff was unsure of the interventions put in place to protect the resident from further victimization.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of the Assistant Director of Nursing (ADON) during wound care for a resident. The resident, an elderly female with diagnoses including heart failure, end-stage renal disease, and diabetes, had wounds on her left buttock and right buttock that required specific wound care orders. During an observation, the ADON did not perform hand hygiene or change gloves appropriately while providing wound care, which included cleansing the wounds and applying medications. The ADON was observed not changing gloves or performing hand hygiene after cleansing the wound and before applying a clean dressing, and again after applying Nystatin cream and before handling the resident's personal items. Interviews with the ADON and the Director of Nursing (DON) revealed that the ADON was aware of the hand hygiene protocols but failed to adhere to them during the observed wound care procedure. The facility's policy on hand hygiene, dated June 2020, outlined specific circumstances requiring hand hygiene, including before and after glove changes and when moving from a dirty to a clean area. Despite being in-serviced on hand hygiene prior to the survey, the ADON did not follow these procedures, potentially increasing the risk of infection transmission to the resident.
Failure in Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for its residents, specifically in the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals. This deficiency was observed in the case of a resident who did not receive the correct pain medication as prescribed. The resident, who had a history of A-fib, DVT, unspecified diastolic CHF, unspecified urinary incontinence, and DM, was under hospice care and required pain medication as needed. However, the facility staff failed to document the administration and refusal of a controlled medication, Acetaminophen - Codeine 300 - 30 mg oral tablets, in a correct and timely manner. On one occasion, an LVN removed two tablets from another resident's medication blister pack and attempted to administer them to the resident in question, who refused the medication, suspecting it was incorrect. The LVN did not document the removal of the medication from the blister pack or the resident's refusal on the MAR. Additionally, the facility failed to remove another resident's controlled medications from the medication cart after the resident was discharged, leading to the potential for medication errors and drug diversion. The facility's documentation practices were inadequate, as evidenced by the lack of controlled medication count sheets and discrepancies in medication administration records. The DON was involved in creating a new count sheet to capture the current situation, but the original documentation was incomplete. The facility's policies on medication administration and handling discrepancies were not followed, contributing to the deficiency in pharmaceutical services.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices during transfers, leading to an incident where the resident was improperly transferred by a physical therapy (PT) student. The resident, who had a care plan indicating the need for a Hoyer lift and two-person assistance due to conditions such as osteoporosis, muscle weakness, and lack of coordination, was instead attempted to be transferred by the PT student alone. This resulted in the resident falling and sustaining a fracture that required hospitalization and surgery. The PT student, who was on her first rotation in a long-term care setting, attempted to transfer the resident without the necessary equipment or assistance, despite being aware of the resident's care plan requirements. The PT student had previously only worked with the resident alongside her clinical instructor and had never attempted such a transfer alone. During the incident, the PT student tried multiple times to lift the resident, ultimately resulting in both the resident and the student falling to the floor. Interviews and video evidence revealed that the PT student did not follow the established transfer procedures, which included using a Hoyer lift for the resident. The incident was witnessed by other staff members, and the resident expressed pain and fear following the fall. The facility's policies on resident transfers and supervision were not adhered to, leading to the identification of an Immediate Jeopardy situation by surveyors.
Deficiency in Urinary Incontinence Care and Management
Penalty
Summary
The facility failed to ensure proper care and management for a resident with urinary incontinence and an external urinary collection system. The resident, who was cognitively intact and had a history of chronic kidney disease, congestive heart failure, and urinary incontinence, was admitted with an external catheter appliance. However, the facility did not have physician's orders in place for the management of this system or implement a urinary toileting program. This oversight could lead to poor personal hygiene, impaired skin integrity, and decreased dignity for the resident. Observations revealed that the resident's room had a foul-smelling urine odor, and the PureWick drainage collection canister was not properly managed, as it was filled above the 1000 cc mark with dark yellow, cloudy urine. The CNA assigned to the resident was unable to explain the use or management of the PureWick system and did not provide appropriate incontinence care. The resident expressed discomfort and fear during repositioning, and there were visible signs of skin irritation and redness in the perineal area, buttocks, and upper inner thighs. Interviews with staff, including a CNA and an LVN, indicated a lack of knowledge and training regarding the management of the PureWick system and the implementation of a toileting program. The DON acknowledged the absence of physician orders for the external catheter system and the potential risk of UTIs if not managed properly. The facility also failed to provide a policy and procedure on catheter care upon request, highlighting a deficiency in ensuring appropriate care and services for residents with urinary incontinence.
Failure to Update and Communicate Menu Changes
Penalty
Summary
The facility failed to update and notify residents of menu changes prior to serving meals, which led to residents receiving meals that differed from the posted menu. On a specific lunch meal, residents were served ground beef with sauce, baked rice with peas and carrots, steamed vegetables, a deep-fried egg roll, and strawberry cake with shredded pineapple instead of the posted menu of Mongolian Beef, Fried Rice, Stir Fry Vegetables, Egg roll, and Pineapple Upside cake. The Dietary Manager did not document or make any changes to the listed menu, affecting 92 residents who receive meals from the facility kitchen. Resident #42, who has severe cognitive impairment and multiple health conditions, expressed dissatisfaction with the food, stating it was often hamburger-based and unappealing. The resident was unaware of the option to request alternate meals and had not seen any menus. Interviews with staff revealed that menus were not being distributed to residents, and there was a lack of communication regarding meal preferences and alternatives. The Charge Nurse and LVN B confirmed that they had not seen menus being passed out and that meal choices were often dependent on kitchen availability. The Dietary Supervisor admitted that the menu change was due to a vendor issue, where the ordered beef cubes for the Mongolian Beef meal were not delivered. Instead, ground beef was used, and the menu was not updated to reflect this change. Additionally, the cake mix for the dessert was substituted due to unavailability. The Dietary Supervisor acknowledged the lack of communication with residents about menu changes and the absence of menu distribution, which contributed to residents not receiving meals as expected.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential risks in their care. For Resident #35, the medical records inaccurately indicated a prescription for Pimozide Tablet 2MG for psychosis, despite the resident having no history of psychosis. The resident's records showed diagnoses of depression and schizophrenia, but not psychosis. The Director of Nursing acknowledged the error, attributing it to a mistake in the electronic medical record system, which could lead to inappropriate treatment. For Resident #82, the facility did not update the medical records to reflect the discontinuation of weekly laboratory work orders, including CBC, BMP, and ammonia levels. Although the orders were initially placed, the resident's physician later determined that weekly labs were unnecessary. Despite this, the orders remained active in the system, and the resident did not receive the expected frequency of lab work. The Director of Nursing and the Nurse Practitioner confirmed that the orders should have been discontinued, and the facility monitored the resident for changes in condition instead. These documentation errors could result in residents receiving inaccurate services based on their comprehensive assessments. The facility's policies on psychotherapeutic drug management and laboratory services did not adequately prevent these discrepancies, as evidenced by the incorrect medication indication for Resident #35 and the outdated lab orders for Resident #82.
Inappropriate Foley Catheter Insertion Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections. Specifically, a nurse inserted a Foley catheter into a resident without obtaining a physician's order, which is required for such invasive procedures. The resident, who was admitted with diagnoses including hypertension, Alzheimer's, and anxiety, was noted to have functional bladder incontinence. Despite the resident's complaint of difficulty urinating, there was no documented order for a Foley catheter, nor was there a diagnosis of urinary retention. The nurse, identified as RN E, inserted the catheter after being unable to reach the resident's primary care provider and based on the resident's request. This action was taken without the necessary physician's order, which is against the facility's policy that requires a physician's directive for catheterization. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both acknowledged that the procedure should not have been performed without a physician's order, as it could be contraindicated and potentially harmful to the resident. The facility's policy clearly states that catheterization should only be performed under a physician's order, highlighting the failure to adhere to established protocols.
Unauthorized Medication Storage and Access
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and allowed unauthorized access to medication keys, specifically for one resident. The deficiency was identified when medications, Unisom and Ketoconazole, were found on the bedside table of a resident who was not authorized to self-administer medications. The resident, who had a BIMS score indicating no cognitive impairment, stated that the medications were brought by her sister and used for headaches and itching. The facility's care plan did not indicate that the resident was permitted to self-administer medications. Interviews with facility staff revealed that they were unaware of the resident having medications in her room. The LVN and ADON both stated that the resident was not supposed to have medications in her room without physician orders, as it could lead to overdose or medication interactions. The DON confirmed that the resident had a history of keeping medications in her room and suspected she was hiding them. The facility's policy allowed bedside medication storage only when it did not present a risk to confused residents, which was not adhered to in this case.
Failure to Obtain Immediate Physician Orders for Wound Care
Penalty
Summary
The facility failed to have physician orders for the immediate care of a resident at the time of admission. Specifically, the facility did not have wound care orders for a resident who was admitted with a surgical wound to the right foot. The resident, a [AGE] year-old female with diagnoses including peripheral vascular disease and osteomyelitis, was admitted on [DATE], but wound care orders were not entered until five days later on 03/27/24. This delay in entering wound care orders could place residents at risk for delayed wound healing and wound infection. Interviews and record reviews revealed that the nursing staff did not ensure the hospital discharge orders, which included wound care instructions, were entered into the electronic health record upon admission. The DON acknowledged that the facility's system for reviewing new admission records failed in this instance, as the Interdisciplinary Team did not verify that all necessary orders were in place. The facility's policy required the attending physician to provide specific orders upon admission, but this process was not followed, leading to the deficiency.
Failure to Provide Necessary Wound Care
Penalty
Summary
The facility failed to provide the necessary wound care for a resident with a surgical wound on her right foot, as per the physician's orders. The resident, who was admitted with peripheral vascular disease and osteomyelitis, did not receive the prescribed wound vac treatment on two specific dates. The hospital discharge orders indicated that the wound vac should be changed three times a week, but there were no wound care orders entered into the electronic health record until several days after the resident's admission. This lapse was discovered only after surveyor intervention. Interviews with the resident and various staff members revealed that the facility did not have the necessary equipment for the wound vac upon the resident's admission, and there was a lack of communication and oversight in ensuring the wound care orders were entered and followed. The Director of Nursing (DON) admitted that the interdisciplinary team failed to review the new admission records properly, leading to the omission of wound care for the resident. The resident's primary physician noted that while the wound infection was being controlled by antibiotics, the lack of wound care could potentially delay healing and increase the risk of infection.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for one resident. Specifically, the staff did not transcribe the wound care orders for a resident with peripheral vascular disease and osteomyelitis into the clinical record. The resident was admitted with a surgical wound to the right foot and had hospital discharge orders for a wound vac to be changed three times a week. However, the wound care orders were not entered into the electronic health record until several days after admission, following surveyor intervention. Additionally, the resident reported receiving wound care only twice since admission, and the facility lacked the necessary equipment for the wound vac initially. Furthermore, the facility failed to document the administration of the resident's IV antibiotic, Vancomycin, on two specific dates. The resident's MARs did not reflect the administration of the antibiotic on those dates, although an LVN stated she had administered the medication but forgot to document it. The DON acknowledged the importance of documenting care to ensure residents receive all ordered treatments and to maintain continuity of care. The facility's policy on nursing documentation emphasized the need for MARs to be completed with each medication administered.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat two residents with respect and dignity during meal assistance. LVN A was observed standing between two residents while feeding them, rather than sitting and providing individualized attention. This action was noted to potentially negatively affect the mental and psychological well-being of residents requiring assistance with eating. Resident #1, an elderly female with Alzheimer's disease and other cognitive impairments, was dependent on staff for eating. Resident #2, also an elderly female with severe cognitive impairment, required limited assistance with meals. Both residents' care plans emphasized the need for respectful and attentive assistance during meals. Interviews with the staff, including LVN A, the DON, the ADON, and the Administrator, confirmed that the staff were aware of the requirement to sit while assisting residents with eating to maintain their dignity. LVN A admitted to knowing better and acknowledged the dignity concern. The DON and ADON reiterated the importance of sitting next to residents during meal assistance to ensure their needs were met and to promote a respectful environment. The facility's policies on resident rights and dignity also supported these practices, emphasizing the need to treat residents with respect and to enhance their quality of life.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, CNA B transferred Resident #3 using a mechanical lift without assistance from another staff member, contrary to the facility's policy and training. Resident #3, a [AGE] year-old female with severe cognitive deficits and a history of transient cerebral ischemic attack, dysphasia, and hyperlipidemia, required substantial assistance for transfers but did not have a mechanical lift indicated in her care plan. Despite this, CNA B used the mechanical lift alone, citing the resident's complaint of pain as the reason for her decision. The incident was observed by the ADON, who confirmed that no other staff were present to assist with the lift. Both the ADON and the DON stated that mechanical lifts should be operated by two staff members to ensure resident safety. The facility's policy and recent in-service training also emphasized the need for two caregivers for mechanical lift transfers. Interviews with CNA B and Resident #3's roommate corroborated the observation that the lift was used without additional assistance, highlighting a clear breach of protocol and placing the resident at risk for accidents and injuries.
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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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