The Palms Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Corpus Christi, Texas.
- Location
- 5607 Everhart Rd, Corpus Christi, Texas 78411
- CMS Provider Number
- 455557
- Inspections on file
- 50
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at The Palms Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe dementia and a history of multiple falls did not have a person-centered, comprehensive care plan with measurable objectives to address fall prevention. The care plan included only general interventions and lacked individualized strategies, despite the resident's repeated falls and cognitive impairment. Staff and leadership acknowledged the absence of specific interventions and the challenges in providing adequate supervision.
A CNA made inappropriate and ridiculing comments to a resident with complex medical needs during peri-care, failing to protect the resident's right to be free from verbal abuse. The incident was witnessed on video, reported by the resident and family, and confirmed through staff interviews and record review.
A resident with dementia, stroke, aphasia, and AV block, who was dependent on staff for daily care and had severe cognitive impairment, did not have a comprehensive care plan in place. Staff were unable to locate any care plan documentation in the chart or electronic records, and interviews revealed confusion about responsibility for care plan development following the absence of an MDS nurse.
Two residents did not have their care plans reviewed or updated after comprehensive, quarterly, or change of condition assessments. One resident's care plan was not revised to reflect a transition to hospice care and new opioid orders, while another's care plan had not been updated in over a year and did not address new diagnoses or medications. Staff interviews revealed confusion about responsibility for care plan updates, and facility policy requiring timely care plan revisions was not followed.
A CNA verbally abused a cognitively impaired male resident with dementia and communication deficits by yelling at him in a public hallway, telling him to do things himself and refusing assistance. The resident showed signs of emotional distress and confirmed feeling sad and embarrassed due to the CNA's language and tone. Staff interviews and facility records indicated the CNA had a history of being loud and had previously been told to moderate his behavior, but no prior abuse had been reported.
A facility failed to immediately report and investigate an alleged abuse incident involving a cognitively impaired resident and two other residents. Despite staff awareness of possible inappropriate behavior and conflicting accounts, no physical assessment or formal investigation was conducted, and the incident was not reported to state authorities as required by law and facility policy.
A facility failed to thoroughly investigate and document an alleged abuse incident involving multiple residents with cognitive and mental health impairments. Staff did not perform required assessments or complete incident reports, and interviews revealed that the necessary investigative steps were not followed according to facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not complete or document required Quarterly Elopement Assessments for multiple residents after the previous MDS nurse left and no staff assumed responsibility for tracking due dates, resulting in incomplete medical records and lack of proper resident evaluation.
A resident with depression and intact cognition was addressed in a stern and disrespectful manner by an RN during a post-fall assessment, as captured on surveillance video. Facility leadership confirmed the interaction did not uphold the resident's right to dignity and respect, and the care plan lacked related guidance.
A facility failed to thoroughly investigate missing Clonazepam tablets for a resident with multiple chronic conditions. Only the two LVNs involved were interviewed, while neither the resident, her responsible party, nor other potentially affected residents were included in the investigation. Medication counts were not properly verified, and the facility did not follow its own policy for interviewing all potential witnesses.
A resident identified as at risk for falls was moved from the floor to her bed by an LVN after an unwitnessed fall without first having her vital signs or neurological status checked, contrary to facility policy. Interviews with staff confirmed that the required assessment was not performed prior to moving the resident.
A facility failed to accurately acquire, receive, dispense, and administer a controlled medication for a resident, resulting in 11 missing tablets of Clonazepam. The medication count process was not properly followed, as staff did not consistently verify the physical count together. The investigation was limited to interviewing and drug testing the two nurses involved, without interviewing the resident, responsible party, or other residents at the time.
A resident with multiple complex diagnoses was admitted without medications, personal items, or adequate behavioral information from the previous facility. After exhibiting sexually inappropriate behavior, the facility determined it could not meet the resident's needs and attempted to return the resident the same day without proper coordination or documentation. The original facility refused readmission, resulting in the resident being sent to the hospital due to lack of placement.
A resident with neurological deficits and mobility issues was transferred from bed to wheelchair without the use of a gait belt by a CNA, despite facility policies requiring it. The CNA used the resident's affected arm for support, leading to a struggle during the transfer. The CNA admitted to not having a gait belt on hand, and facility leadership confirmed the oversight, highlighting the risk of potential falls.
A resident with dementia and mobility dependence suffered a dislocated shoulder and broken elbow due to inadequate supervision and handling. The resident reported being improperly handled by an unfamiliar CNA, leading to the injury. Despite staff following protocol and an internal investigation, the cause of the injury remained inconclusive.
A facility failed to include a resident's preferences and activities in their care plan, despite the resident's ability to sign in and out for meals and appointments. The resident, with intact cognitive function and a history of mental health issues, was not provided a care plan reflecting her needs and preferences, as confirmed by interviews with facility staff.
A facility failed to conduct a required PASRR evaluation for a resident with multiple mental health diagnoses, including Alzheimer's and mood disorders. Staff interviews revealed a lack of awareness and understanding of the PASRR process, leading to the oversight. The MDS nurse and coordinator did not complete a Level II evaluation due to misinterpretations of the screening process, and the DON acknowledged the need for system improvements.
A LTC facility failed to update care plans for three residents, leading to discrepancies in their medical records. One resident's care plan did not reflect her current code status, another's did not show the discontinuation of insulin, and a third's was outdated regarding wound care and self-catheterization. These oversights indicate a lack of communication and coordination among the care team.
The facility's kitchen and nutrition rooms were found to have multiple sanitation and food safety deficiencies, including unsanitary conditions, improper food storage, and inadequate staff hygiene practices. Observations revealed issues such as gnats, mold-like substances, and improperly stored food items. Staff interviews indicated a lack of training and awareness of food safety protocols, contributing to the risk of foodborne illnesses.
The facility failed to maintain an effective pest control program in the kitchen, with gnats and a foul odor present in the dish room, and a gaping hole allowing potential rodent entry. The FSM was unaware of the structural issue, and the ADM and MS lacked documentation and awareness of pest control measures. Pest sightings were noted in logs, but invoices were not provided, indicating a failure to adhere to the facility's kitchen policy on pest prevention.
The facility failed to provide written notification of transfer or discharge to two residents, their representatives, and the Ombudsman. One resident was transferred to the ER for low saturation and shortness of breath, while another was hospitalized after a fall. The ADON confirmed that notifications were made verbally by phone, contrary to the facility's policy requiring written notices.
A resident with new diagnoses of serious mental disorders was not referred for a PASRR Level II screening, as required. The facility's MDS coordinator was unaware of the need to update PASRR screenings for significant changes in condition. The DON recognized the deficiency in care planning and PASRR processes, noting the absence of measures to ensure PASRR accuracy during her tenure.
A resident with severe cognitive impairment and multiple medical conditions had her urinary catheter drainage bag repeatedly observed touching the floor, contrary to facility policy. Despite staff awareness of proper procedures, the deficiency persisted, increasing the risk of urinary tract infections.
A facility failed to ensure safe storage of medications in a medication cart, where disinfectant wipes were stored with resident medications, and personal drink items were found. RN A acknowledged the risk of cross-contamination, and the DON confirmed the need for separate storage of chemicals and personal items. The facility's policy requires orderly storage of drugs, but this was not followed, leading to the deficiency.
The facility failed to maintain essential kitchen equipment, including a refrigerator, freezers, and an ice machine, in safe operating condition. Observations revealed a leaking sink, a dangerous electrical box, and contaminated ice machine. The FSM reported these issues to maintenance, but no action was taken. The MS was unaware of several problems and believed the equipment was functioning properly. Maintenance documentation was requested but not provided.
The facility failed to secure a storage room on hall 2400 containing mouthwash with alcohol and shower rooms on halls 200 and 2200 with disinfectants left out. Staff interviews confirmed these areas should have been locked to prevent resident access to hazardous items.
A resident was verbally abused by a staff member, SA, during a confrontation about patio cleaning during a smoke break. Witnesses confirmed SA's use of derogatory language, but the facility's investigation was inconclusive, and SA returned to work. The incident caused the resident significant distress, and other residents reported similar behavior from SA. The facility's response was inadequate, failing to ensure a safe environment as per their abuse prevention and resident rights policies.
A resident experienced verbal abuse from a smoking attendant, who used profane language during a smoking break. Despite facility policies requiring reporting to law enforcement, the incident was not reported, and the attendant was allowed to return to work in a different role. The resident, with no cognitive impairment, felt anxious and unprotected, and the facility's investigation was deemed inconclusive.
A facility failed to securely store a resident's discontinued medication, leaving it accessible in a clear bin on the ADON's office door. The medication, Azithromycin, was meant for a resident with dementia and other health issues. Staff interviews revealed that the medication was mistakenly left in the bin, which was intended for empty blister packs only, violating the facility's policy requiring medications to be stored in a locked box.
A CNA failed to perform proper hand hygiene and under foreskin cleansing during the care of a resident with severe cognitive impairment and a history of UTIs. The CNA did not wash hands after touching contaminated surfaces or use ABHR during glove changes, and did not retract the foreskin for cleaning, contrary to facility guidelines.
Failure to Develop and Implement Individualized, Measurable Fall Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan with measurable objectives and timeframes to address the needs of a resident with severe dementia and a history of falls. The resident, who was admitted with a primary diagnosis of unspecified dementia and demonstrated severe mental impairment, required assistance with activities of daily living and had a history of multiple falls within a three-month period. The care plan identified the resident as a fall risk and listed general interventions such as keeping the bed in a low position, ensuring the call light was within reach, and maintaining a clutter-free environment. However, the care plan did not include individualized or measurable objectives specifically tailored to prevent falls for this resident. Record review and staff interviews revealed that the resident was mobile using a wheelchair and walker, and was independent with transfers but lacked personal safety awareness due to cognitive impairment. Incident reports documented a witnessed fall from the wheelchair while the resident was attempting to pick up a blanket, resulting in hematomas and a subsequent emergency room evaluation. Staff interviews indicated that the resident was not redirectable, and while staff attempted to supervise and redirect her, they acknowledged the lack of specific interventions in the care plan to address her fall risk. Staff also reported that 1:1 supervision was not feasible due to staffing limitations. Further interviews with facility leadership and the hospice case manager confirmed ongoing challenges in identifying effective interventions to prevent falls for the resident. The Director of Nursing and Administrator acknowledged the care plan's lack of specificity and measurable objectives, and noted unsuccessful attempts to find alternative placement for the resident. Despite ongoing communication with the resident's family and hospice provider, the facility had not developed or implemented a comprehensive, individualized care plan to address the resident's fall risk.
Failure to Protect Resident from Verbal Abuse During Personal Care
Penalty
Summary
A certified nursing assistant (CNA) made an insulting and ridiculing comment toward a resident during personal care, failing to protect the resident's right to be free from verbal abuse. The resident, a female with multiple complex medical conditions including neuromuscular dysfunction of the bladder, obstructive uropathy, metabolic encephalopathy, diabetes mellitus, and paraplegia, was bedbound and dependent on staff for all activities of daily living and toileting. The resident had a history of behavioral symptoms, including making false allegations and threats toward staff, but was assessed as having intact cognition. During an episode of peri-care, the CNA was observed on video making a comment to the resident, stating, "Yeah, we know what you like," after the resident confirmed she was clean. The resident immediately expressed that the comment was inappropriate and uncalled for. The CNA then raised her voice and continued to make remarks about the resident's requests for cleaning, indicating frustration and a lack of professionalism. The incident was reported by the resident and her family, and video evidence was provided to facility leadership. Interviews with facility staff revealed uncertainty about whether the CNA's comments constituted verbal abuse, with some staff suggesting the context was unclear or that the relationship between the CNA and the resident involved joking. However, the CNA herself acknowledged that her comments were inappropriate and admitted to being frustrated with the resident's repeated requests for cleaning. The incident was reported to the state, and the CNA was suspended pending investigation. The facility's abuse prevention policy states that residents have the right to be free from all forms of abuse, including verbal and mental abuse.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple complex medical conditions, including unspecified dementia, cerebral infarction, aphasia, and atrioventricular block. Despite the resident's significant cognitive and functional impairments, including severely impaired decision-making skills, memory problems, and dependence on staff for daily activities such as oral hygiene, toileting, showering, and personal hygiene, there was no care plan available in either the electronic or paper chart. Staff interviews revealed confusion and lack of clarity regarding responsibility for care plan development and updates, particularly following the absence of an MDS nurse. The social worker, ADON, and DON all indicated uncertainty about whether a care plan had ever been completed for the resident, and after an extensive search, no documentation of a care plan or care plan meeting could be found. Facility policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, based on thorough assessment. However, in this case, the required care plan was not present, and staff were unable to confirm its existence or completion. This deficiency was identified through interviews and record reviews, which confirmed the absence of the care plan and highlighted gaps in the facility's processes for ensuring timely and consistent care planning for residents with complex needs.
Failure to Review and Revise Care Plans After Assessments and Changes in Condition
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, as well as change of condition assessments. For two residents whose care plans were reviewed, the care plans did not reflect current diagnoses, treatments, or needs. One resident, with diagnoses including unspecified dementia and COPD, was admitted to hospice care and prescribed morphine for pain management, but the care plan was not updated to include these significant changes. The care plan for this resident had not been reviewed or revised since several months prior to the change in condition and new orders. Another resident, with diagnoses including unspecified dementia, type 2 diabetes, coronary artery disease, hypertension, anxiety, and depression, had a quarterly MDS assessment indicating new or ongoing conditions and medications, such as hypertension and a new order for amlodipine. However, the care plan for this resident had not been reviewed, revised, or edited in over a year and did not address the current diagnosis of hypertension or the associated medication. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans, especially in the absence of a dedicated MDS nurse. The social worker and ADON were unsure who was responsible for care plan updates, and the regional MDS nurse confirmed that care plans had not been reviewed or updated as required. Facility policy required care plans to be developed and revised based on ongoing assessments and changes in resident condition, but this was not followed for the residents reviewed.
Verbal Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) verbally abused a male resident with vascular dementia, major depressive disorder, and generalized anxiety disorder. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was observed by a surveyor as the CNA yelled at him in the hallway, telling him to do things himself and stating that no one else would help him. The CNA continued to raise his voice, disregarding a registered nurse's (RN) intervention to lower his tone, and justified his behavior as 'tough love.' The resident was observed holding his coffee cup, looking at staff, and displaying signs of emotional distress, such as looking down and having watery eyes. When interviewed, the resident confirmed through gestures and limited speech that the CNA's language and tone made him feel sad and embarrassed. Staff interviews revealed that the CNA had a history of being loud and had previously been told to tone down his behavior, but there were no prior reports or grievances of abuse from residents or staff. Other residents interviewed denied experiencing or witnessing similar behavior from the CNA. Facility records and staff interviews confirmed that the CNA's actions constituted verbal abuse, as defined by the facility's policies and resident rights statements. The incident was witnessed by multiple staff members, and the facility's documentation indicated that the CNA's conduct was not in accordance with the expected standards of respect and dignity for residents. The resident's care plan and medical history highlighted his vulnerability due to cognitive and communication deficits, further emphasizing the impact of the CNA's actions.
Failure to Timely Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, and/or mistreatment were reported immediately, as required by law and facility policy. Specifically, an incident involving a resident with severe cognitive impairment and other residents was not reported to the state or investigated further, despite multiple staff being aware of allegations of possible sexual abuse or inappropriate behavior. The incident was not documented in the facility's incident and accident reports, and no formal investigation was initiated at the time of the event. The resident at the center of the incident had a history of dementia, cognitive communication deficit, bipolar disorder, alcohol-induced persisting dementia, and depression, with a severely impaired BIMS score indicating significant cognitive impairment. On the night in question, staff observed unusual behavior: one resident refused to enter his room, reporting hearing noises and expressing discomfort, while another was found standing in the dark with his hands over his private area. Staff reported the situation to the charge nurse, who then notified the DON and Administrator. However, neither the charge nurse nor other staff performed a physical assessment or thorough investigation of the residents involved at the time. Interviews revealed that staff and residents provided conflicting accounts, with some staff expressing concern that the incident should have been investigated as possible abuse, especially given the cognitive status of the resident involved. Despite these concerns and the facility's own policies requiring immediate reporting and investigation of such allegations, the DON and Administrator decided not to report the incident to the state, citing denials from the residents involved. The lack of timely reporting, assessment, and documentation constituted a failure to follow both regulatory requirements and the facility's abuse prevention and reporting policies.
Failure to Investigate and Document Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate and respond to an allegation of possible abuse, neglect, or mistreatment involving multiple residents. On the night in question, a CNA observed one resident sitting outside his room, expressing discomfort about entering due to noises and activities occurring inside. Upon checking, the CNA found two other residents alone in the dark room, with one standing against the wall covering his private area. The CNA reported this to the charge nurse, who did not perform a physical or environmental assessment of the residents or the room, nor did she further investigate the situation before escalating the matter to the DON and Administrator. The DON and Administrator arrived at the facility and interviewed the residents involved, all of whom denied any inappropriate behavior or sexual activity. However, no incident report was completed for the event, and there was no documentation of a thorough investigation, including physical assessments or interviews with all potentially involved parties. Staff interviews revealed that the charge nurse did not assess the residents or the environment, and the DON later acknowledged that a complete investigation, including required documentation and assessments, was not conducted. Additionally, the facility's own policies required prompt and thorough investigation and reporting of all alleged violations, which was not followed in this case. The residents involved had significant cognitive and mental health diagnoses, with at least one resident having severely impaired cognition and another with a history of mental illness and behavioral issues. Staff statements indicated uncertainty about the capacity of one resident to consent to sexual activity, and there were conflicting accounts regarding what was heard or observed. Despite these complexities, the facility did not ensure that all required investigative steps were taken, nor did it document the incident or protect residents as outlined in its policies.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Complete and Document Quarterly Elopement Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards for five residents, specifically by not completing required Quarterly Elopement Assessments since January 2025. Record review showed that none of the sampled residents had these assessments completed after 01/16/2025. Interviews with staff revealed that the previous MDS nurse had been responsible for creating a calendar to track when these assessments were due, but after her termination, the new MDS nurse did not assume this responsibility, stating it was not part of her job. As a result, neither the charge nurses nor the ADONs created the calendar, and the assessments were not performed. Further interviews with the ADON, MDS nurse, and DON confirmed that the lack of a tracking system led to the omission of the required assessments. The DON acknowledged that nursing staff were supposed to manage the assessment schedule but had not done so, resulting in incomplete documentation. The facility did not have a specific policy regarding Quarterly Elopement Assessments, as confirmed by the Administrator.
Failure to Maintain Resident Dignity During Post-Fall Assessment
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to treat a resident with dignity and respect during a post-fall assessment. The incident involved a female resident with a diagnosis of depression and an intact cognitive status, as indicated by a BIMS score of 13. After an unwitnessed fall in her room, the RN addressed the resident in a stern tone, asking, 'What is wrong with you?' and 'Do you want to break something?' while the resident was still on the floor. This interaction was captured on surveillance video and confirmed through observation and interviews. The resident's comprehensive care plan did not contain information related to dignity or respectful treatment. Interviews with facility leadership, including the ADON, ADM, and DON, confirmed that the resident was not treated with dignity, respect, consideration, or courtesy during the incident. The facility's admission packet also states that residents have the right to be treated with dignity, courtesy, consideration, and respect.
Failure to Thoroughly Investigate Missing Controlled Medication
Penalty
Summary
The facility failed to thoroughly investigate an alleged violation involving missing controlled medication for a resident with end stage renal disease, anxiety, type 2 diabetes, and depression. The incident involved an incorrect count of Clonazepam, with 11 tablets missing, discovered during a routine medication count by two LVNs. Both nurses involved were interviewed, drug tested, and suspended pending investigation, but no other staff, residents, or responsible parties were interviewed at the time of the incident. Despite the resident having intact cognition, as indicated by a BIMS score of 15, neither the resident nor her responsible party was notified or interviewed regarding the missing medication. The facility's investigation did not include interviews with other residents who might have been involved or affected, nor did it verify with the resident whether any doses were missed or if there were any changes in her condition. The facility's own policy required interviewing all potential witnesses and identifying the alleged victim, but these steps were not followed during the initial investigation. Observations also revealed that medication counts were not being properly verified, with one staff member counting while the other only checked the sheet, rather than both verifying the physical count and the documentation. This practice was acknowledged by staff as a potential concern for medication security. The lack of a comprehensive investigation and failure to follow established procedures placed residents at risk of not having their allegations of abuse, neglect, or misappropriation thoroughly or timely investigated.
Failure to Follow Post-Fall Assessment Policy
Penalty
Summary
A deficiency occurred when a resident with diagnoses of depression and muscle wasting, and identified as being at risk for falls, did not receive care in accordance with the facility's post-fall assessment policy. After an unwitnessed fall in her room, surveillance video showed that an LVN entered, briefly checked on the resident, and then supervised her movement from the floor to her bed without first performing vital signs or neurological status checks. The resident's care plan included multiple fall prevention interventions, but the required post-fall assessment was not completed prior to moving her. Interviews with the ADON, LVN, and DON confirmed that the facility's policy requires a licensed nurse to evaluate a resident's condition, including vital signs and neurological status, before moving them after a fall. The LVN involved acknowledged not following this protocol and stated the importance of such assessments to prevent further harm. The facility's policy, last revised in 2014, specifically directs that residents should not be moved until this evaluation is completed, unless absolutely necessary. This protocol was not followed in the incident involving the resident.
Failure to Accurately Account for and Investigate Missing Controlled Medication
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident, specifically regarding the controlled medication Clonazepam 0.125 mg. An incorrect narcotic count was discovered during a shift change, revealing that 11 tablets were missing from the resident's supply. The discrepancy was identified when the oncoming and off-going nurses counted the medication together, and both denied taking the pills. The count had been correct the previous night, and the missing tablets were never recovered. The medication administration records confirmed the loss, showing a decrease in the tablet count between the two shifts. Observations of the medication counting process revealed that the off-going nurse typically only verified the count sheet rather than directly observing the physical count of medications, while the oncoming staff performed the count. This practice did not ensure both parties verified the actual medication count, and the process was not consistently followed as intended. The nurse involved stated she had not been instructed to perform the count differently and acknowledged that not verifying the count could lead to missing or stolen medications. Additionally, the nurse did not perform a count immediately after administering controlled medications during her shift, instead waiting until the end of the shift. The investigation into the missing medication was limited to interviewing and drug testing the two nurses involved, with no interviews conducted with the resident, her responsible party, or other residents at the time of the incident. The resident later confirmed she was not interviewed about the missing medication and denied missing any doses or experiencing increased anxiety. Facility leadership acknowledged that no other staff or residents were interviewed during the initial investigation, and the responsible party was not notified until several months later.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was admitted with multiple diagnoses, including Autistic Disorder, Epilepsy, Dysphasia, and Cognitive Communication Deficit Disorder. Upon admission, the resident arrived without medications, a medication list, personal items, and was soiled. The facility did not receive adequate communication from the discharging facility regarding the resident's behavioral issues, specifically sexually inappropriate behaviors, which were not documented on the face sheet or communicated prior to transfer. After admission, the resident exhibited sexually inappropriate behavior toward female staff, which the facility was unprepared to manage. The Director of Nursing and Administrator determined they could not meet the resident's needs and decided to return the resident to the original facility. The process was not coordinated, and the original facility refused to readmit the resident, leading to involvement from the police and Adult Protective Services. The resident ultimately was sent to the hospital due to lack of placement. The facility's actions did not follow their own Transfer and Discharge policy, which requires written notice, documentation of the reason for transfer or discharge, and communication with the resident, their representative, and the Long-Term Care Ombudsman. The discharge was rushed, lacked proper documentation, and failed to ensure the resident's safety and continuity of care, resulting in the resident being left without appropriate placement.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident with significant medical conditions. The resident, a male with a history of muscle wasting, atrophy, and neurological deficits due to a stroke, required partial to moderate assistance for transfers. Despite these needs, a CNA did not use a gait belt during a transfer from the bed to a wheelchair, which could have compromised the resident's safety. During the transfer, the CNA assisted the resident by holding his left arm, which was affected by hemiplegia, instead of using a gait belt. The resident struggled and staggered during the pivot from the bed to the wheelchair, indicating a lack of stability and balance. The CNA admitted to not having a gait belt on her person, as it was left in her locker, and acknowledged the potential risk of a fall during the transfer. Interviews with the DON and ADON revealed that the CNA should have used a gait belt as a safety precaution, and it was standard practice for CNAs to carry a gait belt. The resident's care plan indicated a need for assistance with transfers, contradicting the ADON's initial statement of the resident's independence. The facility's policies and training materials emphasized the importance of using gait belts for safe resident transfers, which was not adhered to in this instance.
Resident Injury Due to Inadequate Supervision and Handling
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for a resident who suffered a dislocated shoulder and a broken elbow. The resident, who was admitted with diagnoses including vascular dementia and osteoarthritis, was completely dependent on staff for mobility and had impaired cognitive abilities. The care plan indicated the resident was bed-bound and required assistance from two staff members for transfers using a mechanical lift. On the day of the incident, the resident was sent to the hospital for pain in her left arm, where a dislocated shoulder and a later identified broken elbow were diagnosed. Interviews revealed that the resident complained of pain and mentioned being hurt by someone, but could not provide specifics due to her cognitive impairments. The Nurse Practitioner was notified and ordered acetaminophen and an x-ray, but the x-ray was delayed due to the unavailability of a technician. The resident was eventually sent to the hospital for evaluation. The facility conducted an internal investigation, suspending three staff members pending the outcome. Witness statements indicated that repositioning in the shower was completed without issues, and staff demonstrated proper transfer techniques during observations. However, the resident described an incident where she was improperly handled by an unfamiliar CNA, which she claimed caused her injury. The Director of Nurses and the Administrator acknowledged the incident and the delay in obtaining an x-ray, but the investigation did not yield a conclusive finding regarding the cause of the injury.
Failure to Include Resident's Preferences in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident, which included the resident's preferences to leave the building and the necessary actions or long-term goals to meet the resident's needs. The resident, who was admitted with major depressive disorder, schizophrenia, and acute gastritis, had a Brief Interview of Mental Status (BIMS) score indicating intact cognitive function. Despite the resident's ability to sign herself in and out of the facility and her preference to leave for meals or appointments, these activities were not reflected in her care plan. The care plan also lacked details on where the resident would go when leaving the facility, the need for the resident to sign out, and the facility's responsibility to clean the resident's room during her absence. Interviews with facility staff, including a Registered Nurse (RN), Licensed Vocational Nurse (LVN), Social Worker, Director of Nursing (DON), and the Administrator, revealed that the resident's ability to leave the premises was known but not documented in the care plan. The staff acknowledged that the resident's activities, preferences, and goals should have been included in the care plan. The Administrator emphasized the importance of care plans in outlining the resident's permissions and expectations while residing in the facility, yet this was not executed for the resident in question.
Failure to Conduct Required PASRR Evaluation
Penalty
Summary
The facility failed to perform a Preadmission Screening and Resident Review (PASRR) for a resident with mental disorders and intellectual disabilities prior to admission. This oversight involved a resident who was originally admitted in 2018 and readmitted in 2019, with diagnoses including Alzheimer's, dementia with psychotic disturbance, mood disorder, psychotic disorder, anxiety disorder, and major depressive disorder. Despite these diagnoses, the resident's PASRR Level I screening was negative for mental illness or intellectual developmental disabilities, and a Level II evaluation was not conducted as required. Interviews with facility staff revealed a lack of awareness and understanding of the PASRR process. The MDS nurse admitted to missing the requirement for a Level II evaluation due to the resident's dementia diagnosis, which automatically greyed out the need for further screening on the forms used. The MDS coordinator also indicated that a new PASRR was not completed if one had already been done, and was unaware of the need for a new evaluation upon a change in the resident's mental health status. The Director of Nursing acknowledged the need for improvement in the system to ensure accurate data and proper care planning.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for three residents. Resident #8's care plan did not reflect her current code status of Full Code, as it was mistakenly left as Do Not Resuscitate. This oversight was acknowledged by the MDS Coordinator, who admitted that the change in code status was overlooked and not updated in the care plan. The Director of Nursing (DON) also confirmed that the code status should be care planned to guide nursing staff in emergencies, but there was confusion about who was responsible for auditing care plans. Resident #34's care plan was not updated to reflect the discontinuation of insulin use, despite the absence of any active orders for insulin. The care plan still included goals and approaches related to insulin administration, which were outdated. This discrepancy indicates a lack of communication and coordination among the care team, as the care plan was not aligned with the resident's current medical orders. Resident #48's care plan was outdated, as it still included references to wounds and a wound vac that were no longer present. Additionally, the care plan did not document that the resident was changing his own urinary catheter, a practice that had been ongoing for about a year. The staff, including the MDS Coordinator and the ADON, were unaware of this practice, and there was no order or care plan to reflect this self-care activity. The lack of documentation and communication regarding Resident #48's catheter changes highlights a significant gap in the facility's care planning process.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in multiple deficiencies in the kitchen and nutrition rooms. Observations revealed unsanitary conditions, including gnats and a foul odor in the dish room, stained walls and floors, and a leaking ice machine with mold-like substances. Drinking glasses were found with a removable white substance, and the air filter above the refrigerator was covered in a thick, furry substance. Food items such as hot dogs were improperly stored, and freezers were not in good working order, with cracked lids and faulty seals. Kitchen staff were observed not following proper hygiene practices, such as not wearing hairnets or washing hands appropriately. A large spatula with peeling edges and eroded non-stick pans were still in use, posing a risk of contamination. The facility's cleaning schedules were not effectively implemented, as evidenced by the state of the kitchen and the lack of knowledge among staff about the cleaning procedures. The grease barrel was not properly sealed, and expired items were found in the nutrition rooms. Interviews with staff revealed a lack of training and awareness regarding food safety protocols. The dietary manager and other staff members were unaware of the extent of the issues, and there was a lack of communication with maintenance regarding necessary repairs. The facility's policies on sanitation, food storage, and handwashing were not being followed, contributing to the risk of foodborne illnesses among residents.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, specifically in the dish room, where multiple gnats were observed flying, and a foul odor was present. A significant structural issue was noted with a gaping hole approximately 6x6 inches in the base of a wall under the 3-compartment sink, which could allow rodents to enter. Rat droppings were also observed along the baseboard near the hole. These observations were made during an initial tour of the kitchen, and the Food Service Manager (FSM) was unaware of the hole and acknowledged that the gnats had been an ongoing problem. Interviews with the Administrator (ADM) and Maintenance Supervisor (MS) revealed a lack of awareness and documentation regarding pest control measures. The ADM was not aware of the dish room's condition and could not recall the last pest control treatment. The MS indicated that pest control was conducted as needed and monthly, but could not specify the frequency or timing of treatments for gnats. The facility's pest sighting log showed that gnats and rat droppings had been addressed on several occasions, but pest control invoices were not provided. The facility's kitchen policy emphasized the importance of preventing insect and rodent infestations, but the lack of documentation and awareness suggests a failure to adhere to these procedures.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to two residents, their resident representatives, and the Office of the State Long-Term Care Ombudsman. This deficiency was identified during interviews and record reviews for two residents who were transferred to the hospital. Resident #37, a male with multiple diagnoses including Type 2 Diabetes and Covid-19, was transferred to the emergency room for low saturation and shortness of breath. The Assistant Director of Nursing (ADON) confirmed that the resident's representative was only notified verbally by phone, and no written notice was provided. Similarly, Resident #81, who had a history of a right femur fracture and other medical conditions, was transferred to the hospital after a fall. The ADON stated that the resident's representative was also notified by phone, and there was uncertainty about whether the Ombudsman was informed. The facility's policy requires documentation of transfer or discharge details in the medical record and communication with the receiving healthcare provider, but it was not followed in these cases. The Social Worker indicated that she only handled non-medical transfers and discharges and typically notified the Ombudsman via email, which had not occurred recently.
Failure to Update PASRR Screening for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a PASRR Level II screening after the resident received new diagnoses of serious mental disorders, including Anxiety, Bipolar with Severe Psychotic Features, Adjustment Disorder, Suicidal Ideations, Depression, Personality Disorder, and Mood Disorder. The resident's PASRR evaluation did not reflect these mental health conditions, as it showed no evidence of a primary diagnosis of dementia, mental illness, or intellectual disability. Despite the resident being prescribed antianxiety and antipsychotic medications and a consult with Senior Psych Care, the necessary PASRR Level II review was not conducted. Interviews with the MDS coordinator revealed a lack of awareness regarding the need to update PASRR screenings for residents with new mental health diagnoses or significant changes in condition. The MDS coordinator believed that a new PASRR was unnecessary if one had already been completed unless the resident had a diagnosis of dementia or was evaluated at a psychiatric hospital. The DON acknowledged the need for improvement in the system to ensure PASRR accuracy and admitted that no measures had been implemented during her three-month tenure to address this issue. The DON also noted a failure in care planning and PASRR processes, indicating a need for better documentation and focus on patient needs.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter drainage bag did not touch the floor, which could increase the risk of urinary tract infections. The resident, a female with severe cognitive impairment and multiple medical conditions including neuromuscular dysfunction of the bladder and end-stage renal disease, required extensive assistance with daily activities. Her care plan included specific instructions for catheter care, such as keeping the drainage bag off the floor to prevent infection. Observations revealed that the resident's urinary catheter drainage bag was repeatedly found touching the floor, despite staff being aware of the proper procedures. On two separate occasions, the drainage bag was observed touching the floor, and staff had to be reminded to hang it higher. Interviews with staff members, including a CNA and an LVN, indicated that while they were aware of the importance of keeping the bag off the floor, there was a lapse in consistently following this protocol. The facility's policy and procedure for catheter care clearly stated that the drainage bag should be kept off the floor to minimize the risk of urinary tract infections. However, the failure to adhere to this policy was evident in the observations and staff interviews. The Director of Nursing acknowledged the importance of keeping the drainage bag off the floor to prevent infections and stated that staff were regularly in-serviced on catheter care, yet the deficiency persisted.
Improper Storage of Medications and Personal Items in Medication Cart
Penalty
Summary
The facility failed to ensure the safe storage of drugs and biologicals in one of the medication carts, specifically the 300-hall cart. During an observation, it was found that disinfectant wipes were stored in the same compartment as various resident liquid medications. Additionally, personal drink items, including an open water bottle and a closed energy drink, were found in the medication cart. This improper storage practice was acknowledged by RN A, who admitted that personal items should not be stored in the medication cart due to the risk of cross-contamination. RN A also recognized that disinfectant wipes, being chemicals, should be stored separately from medications. The Director of Nursing (DON) confirmed that personal items should not be in medication carts to prevent cross-contamination and that disinfectant wipes should be stored separately from medications. The facility's policy on medication storage emphasizes the need for safe, secure, and orderly storage of drugs and biologicals, with specific instructions for separating antiseptics, disinfectants, and germicides from regular medications. Despite these guidelines, the facility failed to adhere to its policy, leading to the observed deficiencies.
Facility Fails to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, which included a stainless-steel refrigerator, two chest type freezers, a refrigerator intake filter, an electrical box, and a sink drain. Observations revealed a dripping sink drain causing a foul odor in the dish room, an electrical box with a dangerous open hole, and an ice machine with visible contamination and leaks. The kitchen staff, including the Food Service Manager (FSM), acknowledged these issues, noting that the ice machine had been leaking for several months and that maintenance had been informed but no action was taken. The FSM also reported that the seals on the chest type freezers needed replacement and that freezer A had a cracked lid. The Maintenance Supervisor (MS) was unaware of several issues, including the dirty air filter above the refrigerator and the state of the dish room. He mentioned that there was a bid for a new ice machine and that the stainless-steel freezer was being serviced. Despite the FSM's reports, the MS believed the freezers were functioning properly and attributed ice formation to staff leaving the lids open. The facility's maintenance log and policy were requested but not provided, indicating a lack of documentation and communication regarding maintenance needs. These deficiencies could potentially place residents at risk of foodborne illness and kitchen staff at risk of injury.
Unlocked Storage and Shower Rooms Pose Safety Risks
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in three of the eight halls reviewed. Specifically, a storage room on hall 2400 was left unlocked while not in use, containing approximately 20 unopened bottles of mouthwash with alcohol. Additionally, shower rooms on halls 200 and 2200 were also left unlocked while not in use, with bottles of disinfectant left out in the open. These observations were made during a survey on August 25, 2024. Interviews with staff, including an LVN, RN, CNA, the Administrator, and the DON, revealed that the storage and shower rooms should have been locked to prevent resident access to potentially hazardous items. The staff acknowledged that mouthwash containing alcohol should not have been present in the facility, and the disinfectant should have been secured in a locked cabinet. The facility's policy on hazardous areas emphasized the importance of securing areas with potential environmental hazards to prevent resident access.
Verbal Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, identified as SA, on April 29, 2024. The incident occurred when the resident confronted SA about washing the patio during a smoke break, leading to SA responding with derogatory language. Witnesses corroborated the resident's account, confirming that SA used inappropriate language. Despite the resident's immediate report to the Administrator, the facility's investigation was deemed inconclusive, and SA was not terminated but returned to work shortly after the incident. The resident involved was a female with a history of depression and diabetes, and her cognitive assessment indicated intact cognition. The incident caused the resident to feel embarrassed and anxious, particularly when she later saw SA working near her room, which heightened her fear and anxiety. Other residents and staff reported that SA frequently used abusive language towards residents, indicating a pattern of behavior that was not adequately addressed by the facility. The facility's policies on abuse prevention and resident rights emphasize the importance of a safe environment and protection from abuse. However, the Administrator's response to the incident, including the decision not to involve law enforcement and the lack of follow-up on the resident's well-being, suggests a failure to uphold these policies. The resident expressed feeling unprotected and fearful of future incidents, highlighting the facility's inadequate response to the verbal abuse incident.
Failure to Report and Address Verbal Abuse Incident
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation, as evidenced by an incident involving a resident who experienced verbal abuse from a smoking attendant. The incident occurred when the smoking attendant became upset with the resident and used profane language towards her during a smoking break. This incident was witnessed and confirmed by four other residents. Despite the facility's policy requiring the reporting of such incidents to law enforcement, the facility did not contact local law enforcement, and no case number was assigned. The resident involved in the incident was a female with a history of diabetes, neuropathy, rheumatoid arthritis, heart disease, chronic skin infections, anxiety, and a left below-the-knee amputation. She had a BIMS score indicating no cognitive impairment and required little to no assistance with activities of daily living. After the incident, the resident reported feeling anxious and unprotected, especially when she saw the smoking attendant around the facility after the incident. She expressed her concerns to the social worker and the administrator, but felt that her concerns were not adequately addressed. The facility's administrator initially suspended the smoking attendant and conducted a 1:1 teachable moment with him, but the attendant was allowed to return to work in a different role without a formal suspension. The administrator's investigation concluded as inconclusive, and he did not believe the incident warranted reporting to law enforcement. The facility's policies did not clearly define the consequences for staff who verbally abuse residents, and there was a lack of follow-up to ensure the resident's well-being after the incident.
Improper Storage of Discontinued Medication
Penalty
Summary
The facility failed to securely store all drugs and biologicals in locked compartments, as required by regulations. During an observation, it was found that a nurse had left a resident's discontinued medication in a clear bin attached to the Assistant Director of Nurses' (ADON) office door. This bin was easily accessible to mobile residents and visitors, which is against the facility's policy that requires medications to be stored in a locked box or medication room. The resident involved was an elderly female with a history of dementia, cellulitis, urinary problems, and acute cystitis. Her medication, Azithromycin, was prescribed for an upper respiratory infection and was supposed to be taken over a course of several days. However, the remaining medication was improperly stored in a location accessible to unauthorized individuals, which could have led to misuse or consumption by residents with cognitive impairments. Interviews with the facility's staff, including the administrator, ADONs, and the Director of Nursing (DON), revealed that the medication was mistakenly left in the clear bin, which was intended only for empty blister packs. The staff acknowledged that the medication should have been stored in a locked narcotic box and that the clear bin should not have been used for storing medications. The facility's policy mandates that discontinued medications be removed from the medication cart and kept under lock and key, which was not followed in this instance.
Inadequate Infection Control During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during the care of a resident. CNA A did not perform hand hygiene during perineal care, which included not washing hands after touching contaminated surfaces and not using alcohol-based hand rub (ABHR) during glove changes. Additionally, CNA A did not perform under foreskin cleansing of the resident's penile area, which is a necessary step to prevent infection. The resident involved was an elderly male with severe cognitive impairment, a history of urinary tract infections (UTIs), and other medical conditions such as dementia and acute upper respiratory failure. The resident was dependent on staff for all activities of daily living, including perineal care, due to his cognitive and physical limitations. The care plan for the resident highlighted the need for thorough perineal care to prevent UTIs, which was not adhered to during the observed incident. During the observation, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) noted that CNA A did not follow the facility's guidelines for infection control, which included retracting the foreskin for cleaning and performing hand hygiene between glove changes. Despite being trained and having completed a competency checkoff for perineal care, CNA A failed to execute the required procedures, potentially exposing the resident to infection risks.
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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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