The Lev At Winchester
Inspection history, citations, penalties and survey trends for this long-term care facility in Alvin, Texas.
- Location
- 1112 Smith Dr, Alvin, Texas 77511
- CMS Provider Number
- 676264
- Inspections on file
- 29
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at The Lev At Winchester during CMS and state inspections, most recent first.
A resident with multiple diagnoses and no cognitive impairment was not included in the development or review of her care plan after her initial admission. Despite regular MDS assessments, there was no evidence of care plan meetings or invitations for her participation, and staff interviews revealed uncertainty about care plan meeting requirements and scheduling.
The facility did not ensure RN coverage for at least eight consecutive hours per day, seven days a week, over several months. Payroll and staffing records showed multiple days, especially weekends, without an RN on duty, leaving staff without necessary RN supervision for nursing activities and emergency coordination. The issue was acknowledged by facility leadership and attributed to staff call-ins and no-shows.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures were not consistently implemented to avoid the development of new ulcers. Surveyors observed lapses in pressure ulcer management and insufficient monitoring of at-risk individuals.
The facility did not provide equal treatment to all residents in matters of transfer, discharge, and services, with differences noted based on payment source.
Two residents with severe cognitive impairment had MDS assessments that failed to accurately document their oral health conditions. One resident was missing all natural teeth and dentures, while another had decayed and missing teeth, but both were incorrectly coded as having no oral issues. Staff interviews confirmed the inaccuracies in the assessments.
A nurse was observed carrying a soiled towel by hand from a resident's room and placing it in a hallway linen barrel without using a bag, contrary to infection control policy. The nurse acknowledged forgetting the required procedure, and the facility's infection preventionist confirmed that soiled linen should be bagged to prevent cross-contamination. The resident involved had multiple chronic health conditions.
The facility failed to ensure proper storage and removal of expired medications from nurse medication carts, with observations revealing expired oral and suppository medications. Interviews with LVNs and the DON highlighted lapses in checking and removing expired medications, contrary to facility policies.
The facility did not have RN coverage for at least eight consecutive hours on a specific day, as required by regulations. This was confirmed by staffing data and the monthly schedule. The DON noted the absence of her signature on the staffing posting for that day, indicating no RN coverage. The Administrator acknowledged the risk of inadequate care guidance without RN presence.
The facility failed to ensure a resident with COPD and dementia received the correct oxygen flow rate as ordered by the physician. Staff members incorrectly set the oxygen flow rate at 2 liters per minute instead of the ordered 3 liters per minute, leading to inadequate respiratory support.
Failure to Involve Resident in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident was given the right to participate in the development and implementation of her person-centered plan of care. Despite having quarterly Minimum Data Set (MDS) assessments completed, there was no evidence that care plan meetings were conducted or that the resident was invited to participate in such meetings after her initial care plan conference. The resident, who had diagnoses including a mental disorder, vascular dementia, multiple sclerosis, and major depressive disorder, and who demonstrated no cognitive impairment with a BIMS score of 14, reported never attending a care plan meeting to discuss her care. She expressed uncertainty about the assistance being provided and her continued stay at the facility, as well as dissatisfaction with the handling of her dental issues. Interviews with facility staff, including the Unit Manager, MDS Nurse, DON, and Administrator, revealed a lack of clarity regarding the scheduling and requirements for care plan meetings. Staff indicated that care plan meetings were typically held upon admission or when requested by family members, but could not confirm that quarterly meetings were held for the resident in question. Review of facility policy indicated that residents should be informed of and participate in care planning at regular intervals, but documentation and staff interviews did not support that this occurred for the resident after her initial admission.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. Record review and interviews revealed that during four out of five months reviewed, there were multiple days when no RN was on duty for the required hours. Specifically, there was no RN coverage on one day in January, three days in February, one day in April, and two days in May. Payroll records and CMS PBJ Staffing Data confirmed these gaps, particularly on weekends, with no RN present on several Saturdays and Sundays across the reviewed months. Interviews with the Administrator and Corporate nurse confirmed awareness of the RN coverage problem, attributing the issue to staff call-ins and no-shows. The facility's own policy requires RN coverage for at least eight consecutive hours daily and designates a full-time RN as Director of Nursing. The lack of RN coverage left staff without supervisory support for RN-specific nursing activities and coordination of emergency care, as noted in the findings.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and review of care practices, indicating that residents did not consistently receive the necessary interventions to manage existing pressure ulcers or prevent new ones from forming. The report notes lapses in the implementation of pressure ulcer prevention protocols and inadequate monitoring of residents at risk for skin breakdown.
Failure to Ensure Equal Treatment Regardless of Payment Source
Penalty
Summary
The facility failed to treat all residents equally regarding transfer, discharge, and the provision of services, regardless of their payment source. This deficiency indicates that some residents may have experienced differences in how they were transferred, discharged, or received services based on their payment method. The report specifically notes the lack of equal treatment but does not provide further details about individual residents or specific incidents.
Inaccurate MDS Assessments of Oral Health Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the oral health status of two residents. For one resident with severe cognitive impairment and a history of dementia, depression, and anxiety, the significant change MDS assessment incorrectly indicated that she had all her natural teeth without problems, despite observations and interviews confirming she had no teeth and was missing her dentures. This resident expressed difficulty eating her provided diet and reported that her dentures had been lost at the facility. Her care plan documented dental problems related to missing dentures, but this was not reflected in the MDS assessment. Another resident, also with severe cognitive impairment and multiple medical diagnoses including vascular dementia and multiple sclerosis, had a comprehensive MDS assessment that failed to note her decaying and missing teeth. Dental records indicated several decayed teeth and a missing crown, and the resident reported pain and a desire to see a dentist. During interviews, both the MDS coordinator and the corporate MDS nurse acknowledged that the assessments were coded incorrectly and did not accurately represent the residents' oral health status.
Failure to Follow Infection Control Protocol for Soiled Linen Handling
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow proper infection control procedures while handling soiled linen. The LVN was observed exiting a resident's room wearing one glove and carrying a large, soiled towel in her hand, which she then transported up the hallway and placed directly into a soiled linen barrel. The LVN admitted during an interview that she was aware of the requirement to transport soiled linen in a bag for infection control purposes but stated she forgot to do so because she was moving too quickly. The facility's infection control preventionist confirmed that soiled linen should be bagged to prevent cross-contamination, in accordance with facility policy and national standards. The resident involved was an elderly female with multiple diagnoses, including heart failure, hypertension, chronic kidney disease, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, and major depression. The incident was documented through observation, staff interviews, and record review, which revealed that the facility's established infection prevention and control program was not properly implemented in this instance. The failure to follow standard precautions and facility policy for handling soiled linen created a risk for cross-contamination and infection transmission among residents, staff, and visitors.
Expired Medications Found in Nurse Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and only authorized personnel had access to the keys for three nurse medication carts. During observations, it was found that two of the three nurses' medication carts contained expired oral medications, and one cart contained expired suppository medication. Specific expired medications included Ondansetron HCL, Benzonatate, Hyoscyamine, Clonidine, and Bisacodyl. These expired medications were discovered during observations with LVN A, LVN B, and the ADON. Interviews with LVN A and LVN B revealed that they had overlooked the expired medications on their carts, acknowledging that expired medications should be removed to prevent administration to residents. The DON confirmed that both nurses and pharmacy staff were responsible for removing expired medications to prevent their use. The facility's policies on medication storage and destruction of unused drugs were reviewed, indicating that unused, contaminated, or expired prescription drugs should be disposed of according to state laws and regulations.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. Specifically, there was no RN coverage on Sunday, June 2, 2024. This deficiency was identified through a review of the CMS' PBJ Staffing Data Report for FY Quarter 2, 2024, which indicated low weekend staffing. The monthly staffing schedule for June 2024 confirmed the absence of RN coverage on the specified date. During interviews, the Director of Nursing (DON) acknowledged that she typically signed the Staffing Daily Posting when filling in for staff, but her signature was absent for June 2, 2024. The DON expressed concerns about the lack of RN coverage affecting resident satisfaction and the ability to address family issues, complaints, or concerns. The Assistant Director of Nursing (ADON) was unable to articulate the risks associated with the deficiency. The Administrator, who had been with the facility for over a year, recognized the state guidelines requiring RN coverage and acknowledged the risk of inadequate guidance for proper resident care without RN presence.
Failure to Provide Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice. Specifically, the facility did not set the oxygen flow rate at 3 liters per minute as ordered for a resident with chronic obstructive pulmonary disease (COPD) and dementia. The resident was observed multiple times holding the nasal cannula (NC) in her hand, and the oxygen flow rate was found to be incorrectly set at 4 and 5 liters per minute by different staff members. The Licensed Vocational Nurse (LVN) and Wound Care Nurse both adjusted the oxygen flow rate to 2 liters per minute, mistakenly believing that was the correct order. The Director of Nursing (DON) was unaware that the resident was adjusting the oxygen flow rate and stated that the nurses were responsible for ensuring the correct flow rate as per the physician's orders. The LVN later reviewed the physician's order and confirmed that the correct flow rate was 3 liters per minute, not 2 liters per minute as she had assumed. The resident's medical history included severe cognitive impairment and a diagnosis of COPD, requiring oxygen therapy. The facility's failure to adhere to the physician's order for the oxygen flow rate could have resulted in inadequate respiratory support for the resident. The facility's Oxygen Administration policy required checking the physician's order for the correct liter flow and method of administration, which was not followed in this case. The LVN admitted to not checking the physician's order and assuming the flow rate based on other residents' orders, leading to the incorrect administration of oxygen therapy for the resident.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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