Vista Hills Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 1599 Lomaland Dr, El Paso, Texas 79935
- CMS Provider Number
- 455493
- Inspections on file
- 45
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Vista Hills Health Care Center during CMS and state inspections, most recent first.
The facility failed to maintain a full-time RN serving as DON, resulting in two distinct periods with no designated DON in place. After the prior DON left, a new DON was briefly hired but soon resigned for health reasons, leaving the position vacant again until another RN was promoted to DON. During these gaps, two ADONs attempted to oversee resident care. The Administrator acknowledged the absence of a DON, confirmed reliance on ADONs, and stated that the facility lacked a specific DON policy and was following state regulations, while recognizing that lack of DON oversight could affect nursing supervision, resident documentation, and response to changes in condition.
Two cognitively intact male residents with diabetes, one with additional psychiatric diagnoses, received blood glucose checks and, for one resident, an insulin injection in an open area near the nurse’s station rather than in a private setting, exposing their medical treatment to others. Facility leadership, including the DON and Administrator, acknowledged that facility policy and practice required such medical treatments to be performed in residents’ rooms to protect privacy and confidentiality of personal and medical records, and that providing these services in public areas was inconsistent with resident rights and privacy standards.
A resident with advanced dementia and severe osteopenia, fully dependent on staff for care, sustained a spiral femur fracture during routine repositioning by a CNA using a one-person assist. The injury was discovered after the CNA heard a popping sound, and although a STAT x-ray was ordered, there was a delay in reviewing the results due to the night nurse's workload. The resident was later transferred to the hospital after the fracture was confirmed.
A resident with advanced dementia and recent orthopedic surgery experienced swelling and pain in the right knee, prompting a STAT x-ray that revealed a spiral femur fracture. Although the radiologist confirmed the fracture late at night, nursing staff did not review the results or arrange hospital transfer until the following morning, resulting in a seven-hour delay in emergency care. Facility staff and leadership acknowledged that the delay was due to lack of follow-up on critical diagnostic results.
A resident with heart failure did not receive four scheduled doses of Entresto due to the medication being unavailable, and staff failed to notify the physician or document the missed doses as required by facility policy. The medication aide recorded the missed doses in the MAR but did not inform the nurse, and the nurse did not notify the physician, resulting in a lack of physician awareness and intervention.
A resident with heart failure did not receive ordered Entresto due to lack of weekend pharmacy delivery and the medication not being available in the facility or from the family. The medication aide did not inform the nurse of the missed doses, and the nurse did not notify the physician or document the incident, contrary to facility policy.
A resident with an indwelling catheter did not have their catheter secured with a leg strap, as required by their care plan and physician's order. The resident reported discomfort due to the unsecured catheter, which had been an issue for two days. Nursing staff, including an RN and a CNA, were trained to secure catheters but failed to do so in this instance. The DON emphasized the importance of regular checks, which were not performed, increasing the risk of catheter-related injury.
The facility failed to address grievances and recommendations from the resident council, particularly regarding cold food temperatures and interference with council elections. Residents felt unheard as their concerns were not documented or acted upon, and they were denied access to meeting minutes. The administrator and staff did not effectively follow the grievance policy, leading to a lack of proper documentation and follow-up on resident issues.
The facility conducted care plan meetings in residents' rooms, compromising privacy and confidentiality. Residents felt embarrassed as discussions were overheard by roommates, staff, and visitors. An LVN and the Administrator were unaware of these concerns, despite the facility's policy emphasizing privacy rights.
The facility failed to resolve grievances, particularly those about cold meals, voiced during Resident Council Meetings. The Activities Director did not initiate grievance reports, and the Administrator did not document or resolve these issues. Residents consistently reported cold meals, but the facility lacked a system to ensure proper food temperatures. The grievance policy was not followed, and the Local Ombudsman confirmed residents felt their concerns were ignored.
A resident with a history of intracerebral hemorrhage and hemiparesis required assistance with ADLs, including nail care. Despite the care plan's instructions, the resident's fingernails were long and dirty, posing a risk of injury due to hand contractures. The DON and staff were either unaware or did not follow through with the necessary nail care, as confirmed by observations and interviews.
A resident with significant medical conditions, including diabetes and limited mobility, did not receive proper foot care due to the facility's failure to provide access to a podiatrist. Observations showed the resident had long, discolored toenails, and staff were not trained or aware of who was responsible for toenail care. The facility's policy required podiatrist care for diabetic residents, which was not provided, placing the resident at risk.
The facility failed to ensure proper documentation of controlled substance counts during shift changes, as three licensed staff members did not follow the established procedure. ADON L did not sign the Controlled Drugs-Count Record immediately after verifying the count, while RN A and LVN C signed the record before conducting the count. This deviation from policy could risk residents not receiving the intended therapeutic response and increase the risk of drug diversion.
The facility failed to ensure proper storage of medications, with oral and topical medications mixed in medication carts and opened Acidophilus Probiotic Dietary Supplements not refrigerated as required. Medication carts were also found to be unclean. In the medication room, oral and topical medications, as well as oral medications and ear drops, were improperly stored together. Staff interviews revealed a lack of awareness regarding proper storage protocols.
The facility failed to serve food at appropriate temperatures, as residents reported meals being delivered cold. The Director of Food and Nutrition confirmed improper food temperatures, and staff interviews revealed a lack of communication and documentation regarding grievances. The facility lacked insulated meal carts and a system to ensure prompt meal delivery, contributing to the issue.
The facility failed to maintain food safety standards, with issues such as unclean shelving, expired foods, and improper food storage. Dietary staff did not use gloves or sanitize thermometers when checking food temperatures. Residents reported cold food, and meal carts were left open, affecting food temperatures.
The facility failed to maintain a safe and sanitary environment, with splintered wood shelves in linen closets, missing baseboards, and chipped walls in the laundry room, and broken tiles and rusted drains in the shower room. Staff interviews revealed a lack of awareness and reporting of these issues, despite existing protocols for maintenance requests.
A facility failed to accurately document a resident's behaviors in her MDS assessment, despite her comprehensive care plan noting behaviors such as requesting HIPAA information and making false allegations against staff. Interviews with staff revealed awareness of these behaviors, but they were not included in the assessment due to their nature. This oversight could lead to inaccurate assessments and affect the care provided.
A facility failed to include a physician-ordered intervention in a resident's care plan, specifically the elevation of the head of the bed to at least 30 degrees during enteral feeding. This oversight was identified during a review of the care plan, despite the resident's medical condition requiring it to prevent aspiration. Observations and interviews revealed that the nursing staff were responsible for ensuring the correct positioning, but the care plan lacked this critical intervention, posing a risk to the resident.
A resident receiving continuous enteral feeding was found lying flat in bed, contrary to physician orders requiring a 30-degree head elevation to prevent aspiration. Despite training, staff failed to maintain this position, as observed during a survey. The facility's policy lacked specific guidance for continuous feeding, contributing to the deficiency.
A facility failed to ensure a resident's feeding tube bags were properly labeled, leading to potential risks. The resident's feeding tube was set correctly, but the enteral feeding bag lacked necessary information, and the water bag was mislabeled. The LVN admitted the mistake, and the DON confirmed no complications but acknowledged the risks.
Failure to Maintain a Full-Time DON Position
Penalty
Summary
The deficiency involves the facility’s failure to designate and employ a full-time registered nurse (RN) as the Director of Nursing (DON) as required by federal regulation 483.35(b)(2). Record review showed that the prior DON’s (DON E) last day worked was 03/03/2026, and the HR Coordinator confirmed his last day of employment as 03/04/2026. A job offer was extended to another RN (DON F) with a start date of 03/18/2026, but payroll records indicated that this DON resigned for health reasons with a termination date of 03/31/2026. A subsequent job offer was extended to another RN (DON D) with an effective date of 04/20/2026. During the surveyor’s on-site investigation on 04/29/2026, DON D was not present at the facility and was reported by the Administrator to be at a sister facility for training. Interviews with the Administrator and DON D confirmed that there was no DON in place from 03/04/2026 through 03/17/2026 and again from 04/01/2026 through 04/19/2026. During these gaps, the facility relied on two Assistant Directors of Nursing (ADONs) to assist with overseeing residents and to compensate for the lack of a DON. The Administrator acknowledged that the facility did not have a DON for the identified periods and stated that the facility had advertised for the position but was seeking candidates with nursing facility experience. The Administrator also stated there were possible barriers for residents when there is no DON, including lack of supervision over nursing staff, issues with residents’ documentation, and potential problems if residents experienced a change in condition. The Administrator further stated that the facility did not have a specific policy for the DON requirement and followed state regulations instead.
Failure to Protect Resident Privacy During Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure residents' rights to personal privacy during medical treatment and personal care for two residents who received glucose monitoring and insulin administration in public areas. On a specified date, staff obtained blood glucose readings for both residents and administered an insulin injection to one resident in an open setting rather than in a private location. These actions occurred despite facility expectations that such care be provided in residents' rooms to protect personal and medical information. Resident #1 was an adult male, initially admitted in January 2025, with a diagnosis of Type 2 diabetes mellitus and prescription orders for multiple diabetic medications, including Insulin Aspart, Tresiba, metformin, and glucagon. His Quarterly MDS showed a BIMS score of 13, indicating he was cognitively intact, and he required insulin injections six days per week. Physician orders directed Insulin Aspart administration three times daily at set times. On the cited date, his glucose reading and insulin injection were provided in a non-private setting, contrary to his care plan focus on diabetes management and the facility’s stated practice. Resident #2 was an adult male with an initial admission in 2019 and readmission in 2024, with diagnoses including diabetes mellitus, dementia, bipolar disorder, and schizophrenia. His Comprehensive MDS documented a BIMS score of 15, indicating he was cognitively intact, and he required insulin injections seven days per week. He also had orders for Insulin Aspart three times daily. On the same date, his glucose reading was obtained in an open area rather than in his room. Interviews with the DON and Administrator confirmed that facility practice and policy required treatments such as glucose checks and insulin injections to be completed in residents’ rooms to maintain privacy and confidentiality of medical information, and that providing such care in open areas was inconsistent with the facility’s resident rights and privacy policy. Record review of the facility’s undated Resident Rights policy stated that residents have the right to personal privacy and confidentiality of personal and medical records, and that personal privacy includes accommodations, medical treatment, and personal care. The DON stated that privacy protections included administering orders in a private setting and that care needed to be completed in residents’ rooms, describing provision of such care in open areas as a HIPAA violation because it could share diagnosis information with others nearby. The Administrator similarly stated that glucose readings and insulin injections should be completed in residents’ rooms due to privacy concerns and that performing these treatments at the nurse’s station exposed residents’ diagnoses and treatments. Documentation from the HR coordinator showed the last facility-wide in-service on resident rights occurred in November 2025.
Failure to Provide Adequate Supervision and Safe Handling During Repositioning
Penalty
Summary
A deficiency occurred when a resident with advanced dementia, severe osteopenia, and a history of multiple comorbidities, including PEG-tube dependence and prior bilateral knee and hip arthroplasties, sustained a spiral fracture of the distal right femur during routine repositioning in bed by a CNA. The resident was completely dependent on staff for activities of daily living and ambulation, and was nonverbal, rarely or never understood, and always incontinent. During incontinence care, the CNA reported hearing a popping sound from the resident's right knee while using a one-person assist technique, after which the resident did not vocalize pain but was later found to have swelling, redness, and pain in the right knee. The CNA had previously performed care for the resident independently and was unaware of the subsequent hospital transfer. Following the incident, the nurse on duty was notified and assessed the resident, noting signs of pain and swelling in the right knee. A STAT x-ray was ordered, and pain medication was administered. However, there was a delay in reviewing the STAT x-ray results, as the night shift nurse did not access the provider portal to check for results, citing workload and being the only nurse for 30 patients. The x-ray provider did not call the facility with critical findings during the night shift, and the results were not reviewed until the following morning by the incoming nurse, who then promptly contacted the provider and arranged for the resident's transfer to the hospital. Interviews with staff confirmed that the resident did not fall and that the injury likely resulted from minimal movement due to underlying bone fragility. The facility's policies required prompt notification of changes in resident status and timely review of diagnostic results. The delay in reviewing the STAT x-ray and the use of a one-person assist for a highly dependent, nonverbal resident contributed to the failure to provide adequate supervision and safe handling techniques, resulting in the resident's injury.
Delay in Emergency Transfer Following Missed STAT X-ray Result
Penalty
Summary
A deficiency occurred when facility staff failed to act in a timely manner to transfer a resident to the hospital after a radiologist confirmed a spiral femur fracture. The resident, an elderly female with advanced dementia, PEG tube dependence, and a history of recent right distal femur fracture, was identified as having swelling, redness, and pain in her right knee during evening care. A STAT x-ray was ordered, and the radiologist signed off on the diagnosis of a spiral femur fracture late that night. However, the resident was not transferred to the hospital until the following morning, resulting in a delay of approximately seven hours from the time the critical finding was available. The delay was due to a lack of follow-up by the night shift nurse, who did not check the x-ray provider portal for results during his shift, despite being aware that STAT x-rays had been ordered and that the resident had a significant change in condition. The nurse stated he was the only nurse for 30 patients and was busy, but acknowledged that it was good clinical practice to follow up on pending x-ray results. The morning shift nurse discovered the x-ray results, contacted the provider, and arranged for the resident's transfer to the hospital. Interviews with other staff confirmed that all nurses had access to the x-ray provider portal and were trained to check for STAT results, and that a fracture was considered a critical finding requiring immediate action. Facility policies required staff to provide timely care and follow up on significant changes in condition, including obtaining and acting on diagnostic results. The failure to review and act on the STAT x-ray results in a timely manner resulted in a delay in emergency care for the resident, who remained in the facility with a confirmed femur fracture for several hours before being transferred for appropriate medical treatment. This delay was acknowledged by facility leadership and staff as not meeting the standard for rapid response to critical findings.
Failure to Notify Physician of Missed Heart Failure Medication Doses
Penalty
Summary
The facility failed to consult with a resident's physician when there was a significant change in the resident's physical status, specifically when four doses of a prescribed heart failure medication (Entresto) were not available and therefore not administered as ordered. The resident, an elderly female with diagnoses of congestive heart failure and sick sinus syndrome, was admitted from home and required Entresto twice daily. Documentation showed that the medication was not administered on four occasions, and the Medication Administration Record (MAR) indicated this with a code, but there was no written documentation in the resident's electronic progress notes that the physician or nurse practitioner was notified of the missed doses. Interviews with facility staff revealed that the process for handling unavailable medications involved notifying the family to bring in medications from home and checking the facility's medication supply system (pyxis). In this case, the family did not provide the medication, and it was not available in the pyxis. The medication aide documented the missed doses in the MAR but did not inform the assigned nurse, and the nurse did not notify the physician. Both the Director of Nursing (DON) and the regional compliance nurse confirmed that staff were trained to notify physicians when medications were not administered as ordered and to document this notification, but this did not occur in this instance. Further interviews with the medical doctor and medical director confirmed that they were not notified about the missed doses, and facility policy required physician notification when medications were not administered. The lack of communication and documentation regarding the missed medication doses resulted in the physician not being able to provide alternative instructions or treatment for the resident.
Failure to Administer Ordered Medication and Notify Physician
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering Entresto Oral Tablet as ordered for a resident with congestive heart failure and sick sinus syndrome. The resident was admitted on a Friday evening, and the facility's pharmacy did not deliver medications on weekends. The facility requested the resident's family to bring in the medication from home, but the Entresto was not provided. The medication was also not available in the facility's pyxis system. As a result, the medication was not administered on multiple scheduled occasions, as documented in the Medication Administration Record (MAR). Interviews with the DON, LVN, and medication aide revealed that the medication aide did not inform the nurse that the medication was not administered, and the nurse did not notify the physician or document the missed doses as required by facility policy. The facility's policy states that if a regularly scheduled medication is withheld or refused, an explanatory note must be entered in the nursing notes or the PRN nurses notes section of the MAR. The medical director confirmed that staff are required to notify physicians when medications are not administered as ordered.
Failure to Secure Catheter Leg Strap
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence. Specifically, the facility did not secure the resident's catheter with a leg strap, as required by the physician's order and the resident's care plan. The resident, who was alert and oriented, reported that the catheter strap had not been in place for two days, causing discomfort due to the catheter shifting. Despite the resident's ability to communicate, the issue was not addressed by the nursing staff, who were responsible for ensuring the catheter was secured. Interviews with the nursing staff, including an RN and a CNA, revealed that they were trained to secure catheters with leg straps and check them regularly. However, the RN admitted to forgetting to verify the leg strap during her assessment, and the CNA was not assigned to the resident but had assisted with perineal care. The Director of Nursing (DON) stated that all staff were required to conduct regular rounds and check catheter placement, but this was not done in this case. The failure to secure the catheter properly increased the risk of it being pulled out accidentally, potentially causing injury or trauma to the urethra.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to consider the views of the residents and act promptly upon the grievances and recommendations of the resident council concerning issues of resident care and life in the facility. The residents felt that the administrator did not make any efforts to address their concerns and grievances discussed in previous months at the resident council meetings. The residents requested copies of the Resident Council minutes to see what efforts had been made to resolve the grievances but were denied access by the administrator. It was reported that the administrator retaliated against the Resident Council President for reporting concerns about her interference with Resident Council Elections, concerns with cold food temperatures, and requests to review Resident Council Minutes. The Activities Director stated that after the resident council meetings, she would complete the grievance form for all concerns voiced and give them to the administrator. However, the administrator claimed to be unaware that not all concerns were being documented in the Resident Council Minutes. The Director of Food and Nutrition acknowledged receiving sporadic concerns about cold food temperatures but did not document these concerns or conduct regular checks on food temperatures. The facility's grievance policy outlines that the administrator is responsible for maintaining a system to keep records of all complaints and ensuring timely responses, but this was not effectively implemented. The facility's QAPI meetings, which are supposed to address various concerns, did not consistently include all relevant department heads, and the issues discussed did not reflect the residents' grievances about cold food temperatures. The review of Resident Council Minutes from May to October did not document any concerns related to cold food temperatures, indicating a lack of proper documentation and follow-up on resident grievances. The facility's failure to document and address the residents' concerns could lead to residents feeling unheard and unvalued in their place of residence.
Violation of Resident Privacy During Care Plan Meetings
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by conducting care plan meetings in residents' rooms. This practice was revealed during a confidential group interview with residents, who expressed feelings of embarrassment and a violation of their privacy due to the presence of roommates, staff members, and visitors who could overhear the discussions. An interview with an LVN MDS Nurse confirmed that care plans were conducted in resident rooms, and she was unaware of any resident concerns about this practice. The facility's Administrator was also unaware of the issue and acknowledged that care plans should be discussed individually and in private. The Nursing Facility Residents' Rights document from November 2021 emphasizes the right to privacy and confidentiality, which was not upheld in this instance.
Failure to Address Resident Grievances and Cold Meal Service
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances, particularly those voiced during Resident Council Meetings. The Activities Director did not initiate grievance reports for concerns raised by residents, and the Administrator did not document or resolve grievances related to quality of care. This lack of action resulted in residents not receiving responses to their grievances, which included ongoing issues with meals being delivered cold. Interviews with residents revealed that meals were consistently served cold, a problem that had not been addressed despite being reported. The Administrator was unaware of these grievances, and the Director of Food and Nutrition acknowledged occasional complaints but lacked a system to ensure food was served at appropriate temperatures. The facility did not have insulated meal carts, and meal trays were not promptly served, contributing to the issue. The facility's grievance policy was not followed, as the Administrator did not complete grievance forms for all concerns expressed by residents. The policy required that all adverse events be investigated and documented, but this was not done. The Local Ombudsman confirmed that residents felt their grievances were not being addressed, and the facility's QAPI meetings did not document concerns about cold food, indicating a failure in the grievance resolution process.
Failure to Provide Adequate Nail Care for Resident with ADL Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform them independently. The resident, a 61-year-old female with a history of intracerebral hemorrhage, non-verbal status, and hemiparesis, required maximal assistance with personal hygiene and bathing. Despite the care plan indicating the need for regular nail care, the resident was observed to have long and dirty fingernails, which had not been trimmed since her admission. This oversight was confirmed by the resident's family member, who expressed concern about potential injury from the long nails. During observations and interviews, the Director of Nursing (DON) and other staff members acknowledged the resident's long fingernails and the associated risk of injury due to her hand contractures. The DON was unaware of any doctor's order for hand rolls to alleviate pressure on the resident's palms. Additionally, staff members, including an LVN and a CNA, were either unaware of the responsibility for nail care or confirmed the need for trimming. The facility's policy on nail care, which emphasizes regular maintenance to prevent infection and injury, was not adhered to in this case.
Failure to Provide Proper Foot Care for Resident
Penalty
Summary
The facility failed to provide proper foot care for a resident, identified as Resident #27, who was at risk due to her medical conditions. Resident #27, a 61-year-old female with a history of intracerebral hemorrhage, diabetes, and other significant health issues, required assistance with personal hygiene and bathing. Despite her need for specialized foot care due to her diabetes and limited mobility, the facility did not provide access to a podiatrist. The Director of Nursing (DON) confirmed that there was no in-house podiatrist and that Resident #27 had not been seen by one since her admission, as her tracheotomy prevented her from leaving the facility. Observations and interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), revealed that Resident #27 had long, discolored toenails, which posed a risk of injury. The LVN admitted to not being trained in toenail care and was unaware of who was responsible for trimming the resident's toenails. The facility's policy stated that nail care, especially for residents with diabetes, should be performed by a podiatrist. However, this standard was not met, placing Resident #27 at risk of poor foot hygiene and potential physical decline.
Failure to Properly Document Controlled Substance Counts
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that controlled substances were properly accounted for and documented during shift changes. Specifically, three licensed staff members, including ADON L, RN A, and LVN C, did not adhere to the established procedure of signing the Controlled Drugs-Count Record immediately after verifying the controlled substances with the on-coming or off-going nurse. This lapse in procedure was observed during a record review and interviews, where it was noted that ADON L did not sign the record immediately after the count, while RN A and LVN C signed the record before conducting the count, contrary to the facility's policy. The facility's policy, revised in 2017, mandates that a narcotics audit be conducted at each shift change to prevent discrepancies, with the involved nurses signing the Narcotic Checklist at the time of the audit. However, the actions of the staff members deviated from this policy, potentially placing residents at risk of not receiving the intended therapeutic response of prescribed medications and increasing the risk of drug diversion. The report highlights the failure of the staff to follow proper procedures for controlled substance counts, which is crucial for ensuring the safety and well-being of the residents.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications across multiple areas, including three medication carts and one medication room. Observations revealed that oral and topical medications were not stored according to their routes of administration in the medication carts on halls E, B, and C. Additionally, opened bottles of Acidophilus Probiotic Dietary Supplement were not refrigerated as required, and medication cart drawers were found to be dusty and filled with paper particles. Interviews with staff, including LVNs and Medication Aides, confirmed a lack of awareness regarding the need to refrigerate certain medications after opening, despite the manufacturer's instructions. In the medication room, medications were also improperly stored, with oral and topical medications mixed together, as well as oral medications and ear drops stored in the same container. The facility's Pharmacy policy and procedure manual from 2003 was reviewed, which outlined the proper storage requirements for medications, including the separation of orally administered medications from those used externally. The Regional Compliance Nurse acknowledged that it is the responsibility of the nursing staff to ensure proper medication storage, highlighting a systemic issue in adherence to established protocols.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature, as evidenced by observations, interviews, and record reviews. During a confidential interview with 13 residents, it was revealed that meals were consistently delivered cold, and this issue had not been addressed by the facility. The Director of Food and Nutrition confirmed that the guacamole was not at the appropriate temperature, measuring 43.3 degrees F instead of less than 41 degrees F. Additionally, a test tray revealed that the pozole was 125 degrees F, the quesadilla was 104 degrees F, and the cheesecake was 62 degrees F, indicating that the food was not served at the correct temperatures. Interviews with staff members, including the Activities Director and the Administrator, highlighted a lack of communication and documentation regarding residents' grievances about cold food. The Activities Director mentioned that residents had voiced concerns during council meetings, but these were not documented in the meeting minutes. The Administrator was unaware of these grievances and stated that the corporate staff did not allow residents to review the council minutes, which may have contributed to the lack of awareness and action on the issue. The Director of Food and Nutrition admitted to occasionally receiving complaints about cold food but could not recall when food temperatures were last checked on a test tray. The facility lacked insulated meal carts and a system to ensure prompt meal delivery to residents eating in their rooms. Additionally, it was noted that CNAs were leaving meal carts open, which could affect food temperatures. The facility's Dietary Services Policy & Procedure Manual outlined procedures for maintaining food temperatures, but these were not being followed, as evidenced by the temperature logs and interviews.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed multiple deficiencies, including the presence of food particles on metal shelving in the food preparation area, expired perishable foods in the refrigerator, and improperly stored food in unsealed containers. Additionally, food containers in the refrigerators were not labeled, and the tile floor in the dry food storage area was covered with dust, white stains, and food particles. Containers in the dry storage room were also found to be dusty and unsealed, and a water bottle was found on the floor under the metal shelving. Further observations highlighted that dietary staff did not use gloves while taking food temperatures and failed to sanitize the food thermometer between uses. The Director of Food and Nutrition was observed not washing hands before checking food temperatures and inconsistently cleaning the thermometer, sometimes using a paper towel or stabbing the plastic cover on food trays. Interviews revealed that residents occasionally complained about cold food temperatures, and there was no system in place to ensure meal trays were promptly served. The facility lacked insulated meal carts, and meal carts were left open in resident halls, potentially affecting food temperatures.
Environmental Deficiencies in Facility's Laundry and Shower Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in several areas, including the laundry room, linen closets, and shower room. Observations revealed that the wood shelves in the clean linen closets had splintered edges, which could potentially cause injury to staff or contaminate linens. Additionally, the laundry room was found to have missing floor baseboards and walls with chipped paint and multiple holes. In the shower room, multiple tiles were either missing or broken, and the water drains were rusted, posing a risk of injury to residents. Interviews with facility staff, including the Housekeeping Supervisor, Maintenance Supervisor, and Administrator, indicated a lack of awareness and reporting of these environmental issues. The Housekeeping Supervisor was unaware of the splintered shelves, while the Maintenance Supervisor, who was new to the role, acknowledged the challenges in addressing these issues due to limited assistance. The Administrator expressed concern over the potential harm to residents from the broken tiles and rusted drains and noted that staff had been trained to report such issues using a QR code system. However, it was unclear why these specific issues had not been reported, suggesting a gap in the reporting process or staff adherence to the protocol.
Failure to Accurately Reflect Resident Behaviors in MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the status of a resident, specifically regarding her behaviors. The resident, a female with diagnoses of generalized anxiety, major depressive disorder, and mild cognitive impairment, was not listed as having behaviors on her annual MDS assessment. Despite having a BIMS score indicating intact cognition, her comprehensive care plan noted behaviors such as frequently requesting HIPAA information on other residents and attempting to get staff in trouble. These behaviors required interventions like providing clear explanations of daily care activities and redirecting the resident. Interviews with the MDS Nurse, DON, and Administrator revealed that they were aware of the resident's behaviors, which included asking questions about other residents and making false allegations against staff. The MDS Nurse admitted to not including these behaviors in the MDS assessment, as they were not considered aggressive or combative enough to warrant a medical diagnosis with medication. The Administrator, although not well-versed in MDS assessments, acknowledged the resident's behaviors and the need for redirection and education. The failure to document these behaviors in the MDS assessment could lead to inaccurate and incomplete assessments, potentially affecting the care and services provided to the resident.
Failure to Include Critical Intervention in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to include the physician-ordered intervention of elevating the head of the bed to at least 30 degrees during enteral feeding. This oversight was identified during a review of the resident's care plan, which did not address this critical intervention despite the resident's medical condition requiring it. The resident, who was severely cognitively impaired and on continuous enteral feeding, had a physician's order mandating the head of the bed elevation to prevent aspiration. Observations and interviews revealed that the nursing staff, including CNAs and charge nurses, were responsible for ensuring the resident's head of bed was elevated as required. However, during an observation, it was noted that the resident's head of bed was not elevated as per the physician's order. The ADON acknowledged the risk of aspiration if the head of the bed was not elevated and stated that staff were trained to maintain the correct positioning during their rounds. Interviews with the MDS nurse and the DON confirmed that the care plan lacked the necessary intervention for head of bed elevation, which was an oversight. The MDS nurse admitted to overlooking this intervention, and the DON emphasized the importance of including all physician-ordered interventions in the care plan to ensure proper monitoring and prevent risks such as aspiration. The facility's policy on comprehensive care planning mandates the inclusion of all necessary interventions to meet the resident's needs, which was not adhered to in this case.
Failure to Maintain Proper Bed Elevation for Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding had their head of bed elevated at least 30 degrees as per physician's orders. This deficiency was observed during a survey when the resident was found lying flat in bed while receiving continuous enteral feeding. The resident, who was severely cognitively impaired and had a history of dysphagia, was at risk of aspiration due to this oversight. Interviews with staff, including the Assistant Director of Nursing (ADON), Registered Nurse (RN), and Director of Nursing (DON), revealed that it was the responsibility of CNAs and charge nurses to maintain the head of bed elevation for residents on continuous enteral feeding. Despite receiving training on enteral feeding care, the staff failed to ensure the resident's bed was properly positioned, which was a critical component of the care plan to prevent complications such as aspiration. The facility's policy on gastronomy tube care required residents to be maintained in a semi-high Fowler's position for a specified time following feeding, but did not specify positioning for continuous feeding. The lack of adherence to the physician's order and facility policy contributed to the deficiency, as staff did not consistently check and maintain the required bed elevation during their rounds, increasing the risk of aspiration for the resident.
Failure to Properly Label Feeding Tube Bags
Penalty
Summary
The facility failed to ensure that a resident's feeding tube bags were properly labeled with the resident's name, date, and time the administration began. This deficiency was observed in a resident who had a feeding tube due to dysphagia and gastrostomy status. The resident's feeding tube was set at the correct rate of 60 ml/hr, but the enteral feeding bag was not labeled with the necessary information. Additionally, the water bag had an incorrect label indicating a different feeding formula and rate. The LVN responsible for changing the feeding bag admitted that the label might have fallen off and acknowledged the mistake in labeling the water bag incorrectly. The Director of Nursing (DON) confirmed that the resident had not experienced any significant weight loss or gain or any complications related to the tube feeding. However, the DON acknowledged the risks associated with failing to label the enteral feeding bag, including the possibility of using an expired or incorrect product. The facility's policy on gastrostomy tube care, which requires labeling and dating of formula and feedings, was not followed in this instance.
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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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