Village Creek Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lumberton, Texas.
- Location
- 705 N Main St, Lumberton, Texas 77657
- CMS Provider Number
- 675975
- Inspections on file
- 34
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 16 (3 serious)
Citation history
Health deficiencies cited at Village Creek Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse prohibition and reporting policies when two cognitively intact residents in a relationship experienced repeated verbal and physical abuse incidents. One resident with a history of verbally aggressive behavior yelled at and belittled his visually impaired roommate, who reported being upset and wanting to change rooms, but after she recanted, the Administrator did not treat the event as an abuse allegation. Later, a CNA documented that the same resident called his roommate a severe derogatory name, but this was not recognized or reported to the Abuse Coordinator or state agency as required. On another occasion, a CNA and an MA saw the resident shove his roommate in her wheelchair into trash and dirty linen barrels, yet both stated they did not consider it abuse and did not report it. These inactions, despite clear policy definitions of verbal and physical abuse and required steps for resident-to-resident incidents, resulted in a cited deficiency and an Immediate Jeopardy finding.
AED Not Properly Checked or Staff Competency Not Ensured: Staff failed to demonstrate competency with the facility’s only AED, which was found beeping with a red X indicator and disconnected electrode pads. Multiple LPNs said they were not trained on the specific AED in use and did not know what the warning indicators meant, while the DON confirmed readiness checks were assigned to night nurses and that prior training had used a different AED.
A resident with a suprapubic catheter, severe cognitive impairment, and multiple urinary diagnoses had blood in the catheter tubing and drainage bag, along with groin pain and blood in his brief, but nursing staff did not document the findings or promptly notify the MD. Staff said they were used to seeing blood in the urine and did not assess vital signs or report the change in condition. The resident also did not have the ordered suprapubic strap in place.
Failure to notify the physician of repeated held antihypertensive medication. A resident with Alzheimer’s disease, dementia, and HTN had Olmesartan ordered with hold parameters for low BP. Nursing staff held the medication on 14 of 23 days because BP readings were outside parameters, but the charge nurse and physician were not notified, and there was no documentation of physician notification in the chart. The DON acknowledged the repeated holds were not communicated, and the physician stated he was unaware of the pattern.
Improper G-tube Medication Administration: Two residents with G-tubes and dysphagia had medication passes that did not follow ordered flush procedures. An LPN administered meds without water flushes before, between, or after doses for one resident, and another LPN mixed crushed meds with a GlycoLax/water mixture and used that mixture to flush the tube and administer meds for another resident instead of using water. The DON stated G-tubes should be flushed with water before, between, and after meds, and the facility policy required each medication to be given separately with water used for dilution and flushing.
Medication administration errors exceeded the allowed rate, with 5 errors in 31 opportunities. An LVN gave gastrostomy tube meds without the ordered water flushes and administered metoclopramide during the pass; an MA gave only 1 capsule of docusate sodium when 2 capsules were ordered; and another LVN mixed crushed GT meds with a GlycoLax solution and used that mixture for flushing instead of water. The DON stated GT meds should be flushed with water before, between, and after meds, and the Administrator expected staff to follow the policy.
Medication errors with Midodrine given outside ordered hold parameters. Three residents received Midodrine despite BP readings being above the ordered hold limits. One resident had severe cognitive impairment and multiple complex diagnoses, another had intact cognition with hypotension, and a third had severely impaired cognition with orthostatic hypotension. MAR review showed repeated doses given when SBP and/or DBP were outside the prescriber’s parameters, and staff interviews confirmed they understood the hold orders but still administered the medication.
Planned lunch menu not followed or posted. A resident meal service review found the lunch served did not match the weekly menu, with staff serving spaghetti instead of the planned entrée after a delayed supplier delivery. The DM, DDM, and Administrator stated the menu change was not reflected on the posted weekly menu, and the substitute/everyday menus were not posted in the dining room as required by facility policy.
A resident with dementia, DM2, anxiety, HTN, muscle weakness, and ventricular premature depolarization had a discharge MDS completed and signed, but it was not transmitted to CMS because it was incorrectly labeled do not submit to CMS. The MDS Nurse said she was responsible for verifying the assessment and transmission, while the DON, Administrator, and CCS confirmed MDS assessments were expected to be completed accurately and sent on time.
Unnecessary Medication Administration: A resident with stroke, HTN, and a PEG tube received Carvedilol twice even though her BP was below the ordered hold parameter. The MAR showed the medication was administered when SBP was under 110, and an LPN later stated the entry may have been clicked in error and that she would not have given it if the BP was below parameters. The DON, Administrator, and Regional Nurse stated meds were expected to be given per MD orders and parameters.
An infection prevention and control deficiency occurred when an LVN performed a G-tube dressing change for a resident with a G-tube, impaired cognition, and tube feeding needs without changing gloves or performing hand hygiene between the dirty and clean parts of the task. The LVN touched the clean dressing with gloves used to clean the site, and later acknowledged the correct procedure; the DON and Administrator confirmed gloves should be changed and hand hygiene performed between dirty and clean procedures.
AED Not Ready for Emergency Use The facility failed to keep its only AED in working condition for CPR use. During observation, the unit was beeping, the electrode pads were not attached, and a red X indicator showed it was not safe to use. The DON confirmed the problem and said the night nurses were responsible for readiness checks, while the Administrator said she had not noticed the issue. Record review showed the facility also did not test the AED according to the manufacturer’s guidelines for 23 days, and the checklist used did not capture key readiness items such as the green check, pads, battery status, or beeping.
A resident with severe cognitive impairment and multiple diagnoses was found with unexplained bruising, which was reported by the responsible party to an LVN. The LVN documented the finding but did not notify supervisory staff or the Administrator, contrary to facility policy. As a result, the incident was not investigated promptly, and leadership was unaware until the survey.
A nurse left a medication cart unlocked and unattended at the main nurse station for several minutes, with the cart containing various medications and controlled substances accessible to unauthorized individuals. The nurse responsible admitted to forgetting to lock the cart before leaving to speak with a resident, despite having received in-service training on medication security. Facility leadership and policy confirmed the expectation that medication carts remain locked and attended at all times.
A resident with obesity and coordination issues, requiring two-person assistance for bed mobility, was left unsupervised by a CNA who provided perineal care alone due to inconsistent documentation. This resulted in the resident rolling off the bed and sustaining pain, with staff later discovering discrepancies between the care plan, MDS, and Kardex regarding required assistance.
The facility failed to maintain effective infection control in the laundry area, as a sheer curtain inadequately separated clean and dirty linen, allowing potential cross-contamination. The Laundry Supervisor had requested rubber flaps months prior, but they were not installed until surveyor intervention. The Administrator was unaware of the issue until then.
The facility failed to ensure dietary staff's hair was completely contained with effective hair restraints during food preparation, as observed with two staff members. Despite being trained on hair hygiene, their hair remained unsecured, which could lead to unsanitary food conditions. The Dietary Manager and Administrator confirmed the expectation for complete hair containment, aligning with the facility's policy.
The facility failed to maintain a safe and sanitary environment, with issues in linen/storage rooms, hall ceiling vents, and the nurse's station ceiling. Observations showed stains, discoloration, and exposed attic areas, with water damage from AC duct work sweating. Despite receiving repair bids, no plans were made, and the Administrator could not find a maintenance policy.
Two residents experienced unsanitary conditions in their rooms, with persistent grayish-black spots around light switches and door frames. Despite attempts to clean, the mildew returned, and the facility had not yet addressed the issue. Both residents were cognitively intact and expressed concerns about the environment.
A facility failed to protect a resident from sexual abuse by another resident on two occasions. The male resident, with severe cognitive impairment, was observed engaging in inappropriate behavior with a female resident. Despite instructions to keep him away from female residents, the facility lacked a formal monitoring system. Staff interviews revealed insufficient training on behavior monitoring, and care plans were not updated, placing residents at risk.
The facility failed to implement comprehensive care plans for two residents, resulting in incidents of sexual and emotional abuse. A male resident with cognitive impairment engaged in inappropriate sexual behavior towards a female resident, while another female resident verbally abused a male resident. The care plans lacked necessary interventions, and staff were not adequately trained to monitor and supervise these residents, leading to deficiencies identified by surveyors.
A facility failed to report an allegation of neglect involving a resident with a tracheostomy within the required 24-hour timeframe. The resident's family alleged that tracheostomy care was provided only once a week, contrary to physician orders for care every shift. The previous administrator misread an email containing the allegation, delaying the report to the State Agency. This failure potentially placed residents at risk of harm and distress.
A facility failed to maintain accurate clinical records for a resident, leading to incomplete documentation of ADL care on specific dates. The resident, with a history of cerebral infarction and heart disease, required assistance with daily activities. Interviews with staff revealed that CNAs were expected to document care every shift, but the records were incomplete, and the facility policy indicated that undocumented care was considered not done.
Failure to Implement Abuse Reporting and Protection Policies for Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse prohibition policies and procedures to identify, report, and protect residents from abuse, specifically in relation to two cognitively intact residents who were in a relationship and shared a room. The facility’s Abuse Prohibition Policy defined abuse to include physical, mental, and verbal abuse, and required that any allegation of abuse made by residents, staff, or visitors be reported immediately to the Abuse Coordinator and investigated. The policy also required immediate protection of residents, monitoring of staff and resident behaviors to identify potential abuse, and specific steps for resident‑to‑resident incidents, including separating residents, assessing for injury, notifying the physician and family, completing incident reports, and contacting the Abuse Coordinator. One resident, an adult male with paraplegia, major depressive disorder, and anxiety disorder, and another resident, an adult female with cerebral infarction, severe visual impairment, bipolar disorder, and anxiety disorder, both had intact cognition with BIMS scores of 15/15 and had requested to room together. The male resident had care plan entries documenting a history and potential for verbally aggressive and accusatory behavior toward staff and residents, and episodes of verbal aggression/irritability when care for his girlfriend/roommate was not provided immediately. On one occasion, nursing notes documented that the female resident reported crying and being upset because her boyfriend yelled at and belittled her in front of others, and she expressed a desire to move out of the shared room. The LVN reported this to the social worker, who spoke with the resident; the resident later recanted and stated she loved him, and the male resident stated he had only told her to tell the nurse about her stomach pain. The Administrator was aware of this incident but, based on the recantation, did not consider it reportable and did not treat it as an abuse allegation under the policy. On a subsequent date, a CNA completed a written witness statement indicating she had observed the male resident yell at the female resident and call her a derogatory term, specifically “[f‑ing retard].” The CNA believed the Abuse Coordinator would see this in the statement, but the Administrator later stated she had not seen that portion of the statement. The Administrator acknowledged that such language would constitute verbal abuse and would be reportable to the state agency, yet the incident was not reported to the Abuse Coordinator or to the state agency as required by policy. Later, both a CNA and a medication aide witnessed the male resident pushing the female resident in her wheelchair and shoving her into trash and dirty linen barrels in the hallway. Both staff members stated they did not consider this to be abuse and therefore did not report it to the Administrator or Abuse Coordinator. The Administrator reported she was unaware of this physical incident until informed by the CNA shortly before the surveyor interview and acknowledged that it could be considered physical abuse and would be reportable. These failures to recognize, report, and respond to resident‑to‑resident verbal and physical abuse incidents, despite clear policy requirements and prior knowledge of the male resident’s behavioral history, led to the cited deficiency and the identification of an Immediate Jeopardy situation.
Removal Plan
- Attempted to separate Residents #14 and #55; both residents refused a room change.
- Initiated 1:1 monitoring for Resident #14 due to refusal to change rooms; monitoring to continue until risk is fully mitigated and IDT determines supervision can be safely reduced.
- Reviewed and updated care plans for Residents #14 and #55 to reflect supervision needs and behavioral concerns.
- Provided education to Residents #14 and #55 regarding personal safety and boundaries, risks associated with unsupervised interactions, and the facility’s responsibility to intervene when safety concerns arise; ongoing reinforcement planned.
- Completed a trauma-informed psychosocial assessment for Resident #55 to evaluate for emotional distress, coercion, or unmet needs; continued monitoring initiated.
- Assessed both residents for physical and psychosocial harm; no additional injury identified.
- Completed life satisfaction rounds to ensure no other residents were negatively affected; no negative findings.
- Notified the Medical Director regarding the alleged failure to follow abuse policies and procedures.
- In-serviced Administrator and DON on abuse policy and reporting procedures; competency validated via quiz.
- In-serviced facility staff on abuse policy and reporting procedures; competency validated via quiz; staff not allowed to work next scheduled shift until training completed.
- Incorporated the abuse training material into new hire orientation and ongoing.
- Audited incident reports for the last 3 months to ensure no other reportable incidents were missed; no negative findings.
- Audited grievances for the last 3 months to ensure no other reportable issues were missed; no negative findings.
- Implemented a protocol for resident-to-resident abuse when both residents refuse room change: immediate enhanced supervision, revise care plans, complete IDT review, assess capacity and risks, involve physician and responsible parties, and consider alternative interventions; ongoing reassessment until risk is fully mitigated.
- Established monitoring/QA process: Administrator/DON daily review of all incidents, grievances, and behavior notes, then weekly, then monthly; random staff interviews to validate understanding of abuse reporting; QAPI Committee review; immediate re-education and disciplinary action as indicated.
AED Not Properly Checked or Staff Competency Not Ensured
Penalty
Summary
The facility failed to ensure that nursing staff were competent to use, maintain, and test the only automated external defibrillator (AED) according to the manufacturer’s guidelines. During observation, the AED was found outside the nurse’s station in a black zipped case, intermittently beeping, with the electrode pads not attached and a red X indicator light displayed. When the device was examined, the red X remained lit and the AED indicated that the battery needed to be changed. Interviews with multiple licensed nurses showed that they were not responsible for checking whether the AED was functioning properly, and several stated they had not been trained on the specific AED in use at the facility. One nurse said she had AED training, but the trainer used a different type of AED. Another nurse stated she had not received instruction from the facility on how to check the current AED until the day before the interview. Staff also stated they were unsure what the red X meant, and one nurse said she only checked whether the AED was available as part of a crash cart checklist. The DON stated that the night nurses were responsible for readiness checks and documentation, including checking for expired pads and whether the machine was functioning properly. The DON also stated that the facility’s AED training had been done using a different AED than the one the facility had on hand. The Administrator said she had not noticed the beeping, the disconnected electrodes, or the red X indicator, and was not aware that staff did not know what to check for to determine whether the AED was ready for use. The Medical Director stated he expected the AED to be functioning with all necessary items at all times and said that if nurses were not familiar with the current AED, education was needed.
Failure to Assess and Report Blood in Suprapubic Catheter
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for a resident with an indwelling suprapubic catheter. The resident had multiple diagnoses including neuromuscular dysfunction of the bladder, obstructive and reflux uropathy, an artificial opening to the urinary tract, multidrug resistance, quadriplegia, and severe cognitive impairment with a BIMS score of 0. His care plan identified that he was at risk for frequent UTIs, dislodgement, and other catheter-related complications, and included monitoring and reporting signs of UTI such as blood-tinged urine, cloudiness, no output, fever, chills, altered mental status, and changes in behavior or eating patterns. Staff observed blood in the resident’s suprapubic catheter tubing and drainage bag over several days, including dark red blood, bright red blood, and a clot in the drainage bag. The resident also had blood noted in his brief, and a CNA reported that he said he had pain in his groin region. Nursing documentation did not reflect the blood in the catheter or the resident’s pain until the surveyor intervened. A nurse stated she had seen scant blood in the tubing and drainage bag, did not assess vital signs, did not document the findings, and did not notify the physician because she was used to seeing blood in the resident’s urine. Another nurse stated she noticed dark blood in the drainage bag, did not call the physician because the urine was usually dark, and could not recall why she did not document the catheter change. The resident’s order summary included an order to check the suprapubic leg strap for placement and change it as needed every shift, but the report states he did not have a suprapubic strap in place to prevent dislodgement or trauma. The DON and Administrator stated staff were expected to assess, document, and notify the DON and physician immediately when blood was noted in the catheter tubing or drainage bag. The physician stated he had not been made aware of the blood in the urine and would have ordered testing to determine whether the resident had a UTI or had become septic if notified.
Failure to Notify Physician of Repeated Held Antihypertensive Medication
Penalty
Summary
The facility failed to ensure the physician was notified when Resident #41’s blood pressure medication was held repeatedly because her blood pressure was outside the ordered parameters. Resident #41 was a female resident with diagnoses of Alzheimer’s disease with late onset, dementia, and hypertension. Her quarterly MDS indicated a BIMS score of 6, showing severe cognitive impairment, and her care plan addressed hypertension with interventions to monitor for side effects and give antihypertensive medications as ordered. Resident #41’s March 2026 MAR showed Olmesartan Medoxomil 40 mg daily ordered for hypertension with instructions to hold for SBP less than 110 and DBP less than 60. The medication was held on 14 of 23 days in March because her blood pressure readings were below the ordered parameters or otherwise outside them. The record review showed no documentation in the nurse’s notes that the physician was notified about the repeated holds. During interviews, MA N and MA K stated they did not notify the charge nurse each time the medication was held, and LVN L stated she was not made aware that the medication had been held 14 out of 23 times. The DON reviewed the MAR and acknowledged she had been unaware of the repeated holds and that best practice would be to notify the physician when medications with parameters were held on consecutive occasions. The resident’s physician stated he was not aware the medication had been held 14 times and said he would have reviewed and discontinued the medication if he had been informed.
Improper G-tube Medication Administration
Penalty
Summary
The facility failed to ensure gastrostomy tube medication administration met professional standards of quality for two residents who both had dysphagia and gastrostomy tubes and received most of their nutrition and fluids through the tube. Resident #9 had diagnoses including cerebral infarction, left hemiplegia/hemiparesis, dysphagia, gastroparesis, and a gastrostomy tube. Her care plan and physician orders required the tube to be flushed with water before and after medication administration and between each medication. During observation, an LVN administered medications through the tube without flushing with water before the medications, between the medications, or after the medications. The LVN later stated she did not realize she had not flushed the tube and said she would not have done anything different. Resident #10 had diagnoses including cerebral infarction, left hemiplegia/hemiparesis, dysphagia, and a gastrostomy tube, with severely impaired cognition and a BIMS of 04 out of 15. His care plan and physician orders required the gastrostomy tube to be flushed with water before and after medication administration and between each medication. During observation, an LVN mixed GlycoLax in water and then mixed crushed gastrostomy tube medications with that mixture. The LVN flushed the tube with the GlycoLax mixture instead of water before medication administration and between medications, and also mixed residual medication in the cup with the GlycoLax mixture before continuing with the remaining medications. She stated she would not have done anything different and acknowledged that mixing crushed medication with the GlycoLax/water mixture and flushing after each medication could be considered drug cocktailing. The DON stated gastrostomy tubes should be flushed with water before, after, and between medications, and that medications should not be cocktailed because there could be a reaction of the medications mixed. The Administrator stated she expected staff giving medications to know how to do it correctly and follow the policy. The facility policy required each medication to be administered separately, with water used for dilution and flushing, and directed that the tube be flushed with water between medications and after the last medication.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent. Surveyors identified 5 medication errors out of 31 opportunities, resulting in a 16.13 percent error rate involving 3 of 6 residents reviewed during medication pass observations. The errors involved medication administration through gastrostomy tubes and an oral medication dose that did not match the physician order. For one resident with a gastrostomy tube and orders for NPO status, metoclopramide via tube before meals and at bedtime, and tube flushing with water before and after medications and between each medication, an LVN administered multiple medications through the tube without flushing before, between, or after the medications. The LVN also gave metoclopramide during the medication pass and stated she would not have done anything differently. The LVN later said she did not realize the tube had not been flushed as ordered and believed the metoclopramide order should be clarified as to when to administer. For another resident, an MA administered docusate sodium 100 mg, 1 capsule, even though the physician order was for 2 capsules by mouth twice daily. For a third resident with a gastrostomy tube and orders to flush with water before and after medication administration and between each medication, an LVN mixed GlycoLax with water and then used that mixture to dilute crushed medications and to flush the tube before and between medications, rather than using water. The LVN acknowledged that this could be considered drug cocktailing. The DON and Administrator stated staff should know how to administer medications correctly and follow the policy.
Medication errors with Midodrine given outside ordered hold parameters
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors involving Midodrine, a medication used to raise blood pressure, for 3 of 8 residents reviewed. The report states that Residents #5, #4, and #10 received Midodrine even when their blood pressure readings were outside the physician-ordered hold parameters. The deficiency was identified through record review of physician orders, MARs, care plans, MDS assessments, and staff interviews. Resident #5 had multiple diagnoses including chronic respiratory failure with hypoxia, gastrostomy, quadriplegia, tracheostomy, colostomy, neuromuscular dysfunction of the bladder, multidrug resistance, and atrial fibrillation. His MDS showed severely impaired cognition with a BIMS of 0, and his care plan included administering medications per MD orders and monitoring blood pressure. Physician orders for Midodrine changed over time, with hold parameters listed for elevated SBP and later for SBP greater than 130 and DBP greater than 80. The January, February, and March 2026 MARs showed numerous doses of Midodrine given when blood pressure readings were above the ordered hold parameters. During interviews, multiple nurses acknowledged that Midodrine should have been held when the readings were outside the ordered parameters, and several stated they did not realize they had made medication errors or did not know the medication’s purpose at the time of administration. Resident #4 had a diagnosis of hypotension and intact cognition with a BIMS of 15. His care plan included giving medications as ordered and following physician parameters for medication administration. A physician order directed Midodrine 10 mg every 8 hours with instructions to hold for SBP greater than 130 or DBP greater than 80. The MAR showed doses given when SBP readings were above the hold threshold, including multiple administrations in February and March 2026 when SBP ranged from 132 to 148. Resident #10 had diagnoses including hypotension and orthostatic hypotension, with severely impaired cognition and a BIMS of 4. His care plan also directed staff to give medications as ordered and follow physician parameters. A physician order directed Midodrine 10 mg every 8 hours with instructions to hold for SBP greater than 140 or DBP greater than 90. The MAR showed Midodrine given when DBP was 98, 92, and 91, and when SBP was 145 to 154 with DBP as high as 104.
Planned lunch menu not followed or posted
Penalty
Summary
The facility failed to ensure the planned menus were followed and prepared according to the weekly menu for 1 of 4 meals reviewed, the lunch meal. The weekly menu for 03/23/2026 listed smothered chopped steak, black-eyed peas, spinach, garlic cheese biscuit, sherbert, tableside condiments, water, and a choice of beverage. However, the menu board posted outside the dining room listed a different lunch menu of spaghetti, tossed salad, vegetable blend, garlic cheese biscuit, and sherbert, and there was no substitute or everyday menu posted in the dining room and no weekly menu posted in the dining room. During the dining room observation, residents were served spaghetti noodles with spaghetti sauce containing ground meat, tossed salad, vegetable blend, garlic biscuit, a beverage, and condiments. The DM stated the planned lunch menu was not served because the new supplier had not delivered the order and the DDM told staff to prepare spaghetti instead. The DM also stated the weekly menu had been in a frame in the dining room but had fallen and the glass shattered, and the signage was not replaced. The DM stated the residents had a right to know in advance what they were receiving for meals so they could choose an alternative if they did not like what was being served. The DDM stated the new supplier had provided a menu when the facility changed suppliers, but the supply truck was delayed and the lunch menu had to be changed. He stated the menu change was approved by the RD, but the weekly menu provided to the survey team was not updated. He also stated he was not aware that the alternate substitute menu, everyday available menu, and weekly menu were supposed to be posted in the dining room. The Administrator stated she was not aware the lunch menu had been changed from the scheduled menu and said the weekly scheduled menu was not located in the dining room during the tour, though a weekly scheduled menu was found at the nurses' station. The facility policy stated menus are planned in advance, served as written unless changed for preference, unavailability, or a special meal, and are posted in the nutritional service department, dining room, and resident/patient care areas.
Failure to Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that an encoded, accurate, and complete discharge MDS assessment for one resident was electronically transmitted to the CMS system. Resident #56 was admitted with diagnoses including ventricular premature depolarization, dementia, type 2 diabetes mellitus, anxiety, high blood pressure, and muscle weakness, and the record showed a discharge date of 11/22/2025. The discharge MDS was dated 11/25/2025, with the RN Assessment Coordinator signing it as complete, but the assessment was not transmitted to CMS as required. Record review showed the discharge MDS was completed and signed, and the electronic record listed it among the resident’s MDS assessments, but it remained untransmitted. During interview, the MDS Nurse stated the assessment had been batched and sent to software for submission, but she was unsure why it was not transmitted and later identified that it had been labeled as do not submit to CMS in the transmitting process. The DON, Administrator, and CCS stated the MDS Nurse was responsible for timely completion and transmission of MDS assessments, and the facility policy required non-comprehensive assessments to be submitted within 14 days of the MDS completion date.
Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary medications when Carvedilol, ordered for hypertension, was administered even though the resident’s blood pressure was below the prescribed hold parameter. Resident #9 was a female admitted with diagnoses including stroke affecting her left non-dominant side with paralysis, high blood pressure, and difficulty swallowing with a feeding tube. Her quarterly MDS indicated a BIMS score of 10, showing moderate cognitive impairment, and her care plan included interventions to give hypertension medications, monitor vital signs, notify the MD of significant abnormalities, and assess for side effects. The physician order for Carvedilol 12.5 mg via PEG tube twice daily directed staff to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the January and March 2026 MAR showed the medication was given on two occasions when the blood pressure was outside the ordered parameters, including readings of 109/65 and 106/54. During interview, an LVN stated that if other blood pressure medications were held, she must have clicked the administered box by error and said she would not have given the medication if the blood pressure was below the set parameters. The DON, Administrator, and Regional Nurse stated medications were expected to be administered according to physician orders and parameters, and the facility policy stated medications are administered according to prescriber orders and within the ordered timeframe.
Infection Control Failure During G-Tube Dressing Change
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident observed during a dressing change. Resident #9 was a female admitted with a gastrostomy tube, and her records showed she was rarely understood by others, sometimes understood others, had moderately impaired cognition with a BIMS of 10 out of 15, and received most of her calories and fluid intake through tube feeding. Her care plan and physician orders indicated she required gastrostomy tube site care every shift, including cleansing the site with soap and water, patting dry, applying split gauze, and securing it. During an observation of the gastrostomy tube dressing change, the LVN removed the dressing, cleaned the area, and then, without changing gloves or performing hand hygiene, obtained the clean dressing and applied it to the gastrostomy tube site. She stated she would not have done anything different at the time. Later, she acknowledged that gloves should be changed between dirty and clean procedures, hand hygiene should be performed before putting on clean gloves, and clean items should not be touched with gloves used to clean a wound or gastrostomy tube site. The DON and Administrator also stated that gloves should be changed between dirty and clean procedures and that hand hygiene should be done between glove changes.
AED Not Maintained in Ready-to-Use Condition
Penalty
Summary
The facility failed to maintain a working automated external defibrillator (AED) for emergency CPR use. During an observation, the only AED available in the facility was located outside the nurse’s station in a wall holder, intermittently beeping, with the electrode pads not attached and a red X indicator light showing that it was not in safe operating condition. The DON later removed the AED from its case and confirmed that the pads were not attached and that the device was beeping. The DON stated that the night nurses, LVN H and LVN J, were responsible for conducting readiness checks and documenting them, including checking for expired pads and whether the machine was functioning properly. She said she was not aware the AED was not ready for use. The Administrator also stated she had not noticed the missing electrodes, the beeping, or the red X indicator, and said the nighttime nurses were responsible for checking and documenting the AED each night. The DON and Administrator both indicated that CPR included use of the AED, and the DON said the nurses had been trained on AED use, although the training used a different AED than the one the facility had on hand. Record review showed the old crash cart checklist only had a check mark for AED #1 and did not indicate whether a red X or green check mark was present, whether electrodes were attached, or whether the unit was beeping. A revised form later included fields for daily date, green check visible, no red X, pads present, battery ok, no beeping, issues, and staff initials. The facility’s policy stated that AED equipment was available for emergency use and that the DON or designee would test and document the AED’s operating status according to the manufacturer’s guidelines. The manufacturer’s manual stated the unit should not be used if it displayed a red X or emitted a beeping tone and that the electrode cable should remain connected at all times. Record review also showed the facility had not tested the AED according to the manufacturer’s guidelines for 23 days.
Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an alleged violation involving possible abuse was reported immediately to the Administrator as required by policy. Specifically, a resident with severe cognitive impairment and multiple complex diagnoses, including Type 2 diabetes, seizure disorder, autistic disorder, and cerebral palsy, was found to have several yellow-colored, faded bruises under the upper part of his right arm. The resident's responsible party (RP) noticed the bruising and reported it directly to an LVN, who documented the finding in the nurse's notes but did not escalate the report to the ADON, DON, or Administrator. The LVN assessed the resident, who was unable to communicate how the bruising occurred due to his cognitive impairment, and noted that the resident was not in distress or acting outside his normal behavior. Despite being trained on the facility's policy to report bruises of unknown origin, the LVN did not notify supervisory staff or the Administrator, as required. There was no incident report or grievance filed regarding the bruising, and neither the ADON, DON, nor the Administrator were made aware of the incident until it was brought to their attention during the survey. Facility policy clearly states that all employees must report any allegation of abuse, neglect, or misappropriation of resident property to the Abuse Coordinator immediately, and that all incidents of unknown origin must be investigated. The failure to report the bruising as required resulted in the incident not being investigated in a timely manner, as the appropriate facility leadership was not informed.
Medication Cart Left Unlocked and Unattended by Nurse
Penalty
Summary
A nurse medication cart on Hall 100 was observed to be left unlocked and unattended at the main nurse station for six minutes, with the drawers facing the hallway and the lock mechanism indicating it was unsecured. During this time, the nurse responsible for the cart, LVN E, was in a resident's room with the door closed and out of sight of the cart. The cart contained various medications, including over-the-counter aspirin, vitamins, minerals, eye drops, accu-check strips, glucometers, and a locked compartment with controlled substances and multiple residents' medication bubble-blister packets. The unlocked cart was accessible to unauthorized individuals and residents passing by. LVN E acknowledged responsibility for the cart and admitted to forgetting to lock it before leaving to speak with a resident. She confirmed awareness of the policy requiring the cart to be locked at all times when not in use and stated she had received in-service training on this requirement earlier in the year. The Director of Nursing and the Administrator both confirmed the facility's policy and expectation that medication carts be locked and secured when not in use, and that only authorized personnel should have access to medications. Facility policy documents reviewed also specified that all drugs and biologicals must be stored in locked compartments and that medication carts are not to be left unlocked and unattended.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident, who required assistance with personal care and had a history of morbid obesity and lack of coordination, was not provided adequate supervision and assistance during perineal care in bed. The resident's care plan identified a risk for falls but did not specify the number of staff required for assistance. The Minimum Data Set (MDS) assessment indicated that the resident needed physical assistance from two or more persons for bed mobility, but the Kardex listed only one-person assist. This discrepancy led to a certified nursing assistant (CNA) providing perineal care alone, during which the resident rolled off the bed and fell to the floor. Following the fall, the resident complained of pain in the right arm and was assessed by staff. X-rays were ordered, and the resident's family and physician were notified. Initial mobile x-ray results suggested acute rib fractures, but subsequent hospital imaging did not confirm these findings. The resident reported significant pain after the incident, particularly in the chest and knees. Interviews with staff revealed that the CNA had relied on the Kardex, which indicated one-person assist, despite other documentation requiring two-person assistance. Staff acknowledged the importance of verifying the correct level of assistance in the electronic health record before providing care. Further investigation found inconsistencies between the Kardex, care plan, and MDS assessments regarding the required level of assistance for the resident. The facility's policy required accurate communication and documentation of assistance needs, but this was not followed in this case. The failure to ensure that all care documentation matched and to provide the correct number of staff for bed mobility directly led to the resident's fall and subsequent pain.
Inadequate Infection Control in Laundry Area
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program in the laundry area, which is crucial for preventing cross-contamination and infection. During an observation, it was noted that the laundry area had only a sheer curtain separating clean and dirty linen, allowing airflow between the two areas. This curtain was inadequate, as it left a significant portion of the doorway uncovered, failing to prevent the potential spread of contaminants. The Laundry Supervisor acknowledged the issue, stating that rubber curtain flaps had been requested from the maintenance department months prior, but they had not been installed. The Administrator was unaware of the need for these flaps until the surveyor's intervention, at which point the flaps were reportedly installed. The facility's Laundry Operations policy from 2016 indicated the necessity of a process to sort soiled linen without cross-contaminating clean linen, which was not effectively implemented in this instance.
Failure to Ensure Proper Hair Restraint in Dietary Staff
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that dietary staff members' hair was completely contained with effective hair restraints. During multiple observations, it was noted that Dietary Staff A and Dietary Staff B had hair that was not fully covered by hair restraints while preparing meals for residents. Specifically, Dietary Staff A's hair was observed to be outside the hair restraint at the neckline on several occasions, and Dietary Staff B had hair sprigs eluding from the ears to the neckline area. Both staff members acknowledged they had been trained on hair hygiene, yet their hair remained unsecured during food preparation. The Dietary Manager and the Administrator both confirmed that the expectation was for all dietary employees to have their hair completely contained in hair restraints while involved in food preparation and serving. The facility's policy, dated October 2023, also indicated that all staff members should have their hair off the shoulders and confined in a hair net or cap. The failure to comply with these standards could result in unsanitary conditions, as unsecured hair could potentially land in the food being prepared for residents.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in several areas, including two linen/storage rooms, two hall ceiling vents, and the nurse's station ceiling. Observations revealed that the ceiling above the nurse's station had brown and yellowish stains around the vent, and there was an open area in the sheet rock. Additionally, two of the three vents on Hall 4 were discolored with a grayish substance extending onto the ceiling. In Hall 3's linen storage room, a section of the ceiling had been removed, exposing the attic, and the remaining ceiling was covered with grayish black spots. The room also had a musty smell, and the top shelf was covered with a thick black substance. Hall 2's linen/supply closet had a hole and water damage on the ceiling. Interviews with the Maintenance Supervisor and the Administrator revealed that the water damage occurred due to AC duct work sweating in October and November 2024. Although bids for repairs were received, no decision had been made on the plans for fixing the duct and sheet rock repairs. The Administrator acknowledged the need for maintenance and took pictures of the affected areas to discuss with regional corporate maintenance. However, she was unable to find a policy on maintaining the environment, indicating a lack of documented procedures for addressing such issues.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents, leading to a deficiency in maintaining a sanitary and comfortable living space. Resident #2, who was cognitively intact with a BIMS score of 13, had discoloration in his room, with grayish to black spots around the light switch and electrical receptacle, as well as along the door frames. These spots had been present since his admission, and he expressed a desire for the areas to be painted. Similarly, Resident #13, also cognitively intact with a BIMS score of 14, experienced the same issue with discoloration in his room. He reported that the black and gray spots had been present for months, and although a housekeeper attempted to clean the area with a bleach rag, the mildew persisted. The Administrator acknowledged the issue, noting that bids for water damage repair had been sent to the corporate office, but was unable to provide a policy on maintaining the environment.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident on two separate occasions. The first incident occurred when a male resident was observed flicking the breast of a female resident in the TV room. Despite being removed from the area and notified, the facility did not implement a care plan to prevent further inappropriate behaviors. The second incident involved the same male resident placing his hand inside the female resident's pants while she was in her wheelchair near the nursing station. This incident led to the male resident being placed on one-to-one supervision, but it was discovered that he had an outstanding warrant for continuous sexual abuse of a child. The male resident had a history of severe cognitive impairment and was mobile with a wheelchair, which was not initially recognized by the facility staff. After the first incident, staff were instructed to keep the male resident away from female residents, but there was no formal monitoring system or interventions in place for supervision. The facility's abuse prohibition policy required immediate separation of residents involved in incidents and assessment of the victim, but these measures were not effectively implemented. Interviews with staff revealed a lack of training on monitoring behaviors after inappropriate behavior was identified. The facility's failure to follow its abuse prevention policy and update care plans and interventions placed residents at risk of further incidents. The facility's in-service records indicated that staff were retrained on abuse prevention and reporting, but not all staff had been trained on monitoring behaviors after an inappropriate behavior was identified.
Failure to Implement Comprehensive Care Plans Leads to Abuse Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to incidents of abuse. Resident #1, a male with severe cognitive impairment and a history of brain injury, was involved in two incidents of sexual abuse against Resident #2, a female with severe cognitive impairment and cerebral palsy. Despite these incidents, Resident #1's care plan did not include interventions to address his sexually inappropriate behaviors, and he was not adequately supervised, allowing him to engage in further inappropriate conduct. Resident #3, a female with cognitive intactness and mood disorders, was involved in verbal and emotional abuse towards Resident #4, a male with schizophrenia and intellectual disabilities. Resident #3's care plan did not include interventions to prevent her abusive behavior, despite reports of her making emotionally abusive comments and manipulating Resident #4. The facility's failure to update and implement effective care plans for these residents placed them and others at risk of harm and distress. Interviews with facility staff revealed a lack of awareness and training regarding the supervision and monitoring of residents with identified inappropriate behaviors. The previous MDS LVN responsible for updating care plans admitted to not knowing why the care plans were not updated, and the facility's policy on comprehensive person-centered care plans was not followed. This oversight resulted in the facility being out of compliance, with deficiencies identified by surveyors.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident within the required 24-hour timeframe to the State Agency. The incident involved a resident who had a tracheostomy and was dependent on tracheostomy care and oxygen therapy. The resident's family member alleged that the resident only received tracheostomy care once a week prior to being discharged home, contrary to the physician's orders for tracheostomy care every shift and as needed. This allegation was reported to the facility on April 22, 2024, but was not reported to the State Agency until April 25, 2024, due to the previous administrator misreading an email from the corporate office that contained the allegation. The resident, who was cognitively intact and dependent for all activities of daily living, was at risk of neglect due to the facility's failure to provide the necessary tracheostomy care as per the physician's orders. The facility's records indicated that tracheostomy care was completed as ordered, but the family member's allegation suggested otherwise. The facility's policy required that all allegations of neglect be reported within 24 hours, but this was not adhered to, potentially placing residents at risk of physical harm, mental anguish, and emotional distress.
Incomplete Documentation of ADL Care for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, identified as Resident #5, which is a violation of accepted professional standards and practices. The deficiency was identified during a review of the resident's ADL task sheet, which showed incomplete documentation of care provided on specific dates. Resident #5, a female with a history of cerebral infarction and atherosclerotic heart disease, required varying levels of assistance with daily activities such as bed mobility, toileting, and transferring. However, the ADL task sheet lacked documentation for two consecutive days, raising concerns about the accuracy of the records. Interviews with facility staff, including the ADON and a CNA, revealed that CNAs were expected to document all ADL care assistance on task sheets every shift. Despite this expectation, the documentation for Resident #5 was incomplete, and the ADON acknowledged that the facility policy stated that if care was not documented, it was considered not done. The CNA interviewed could not recall the resident but confirmed that documentation was a recurring issue. The facility's administrator also emphasized the importance of accurate documentation to ensure residents receive necessary services.
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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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