Vista Ridge Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewisville, Texas.
- Location
- 700 E Vista Ridge Mall Dr, Lewisville, Texas 75067
- CMS Provider Number
- 676036
- Inspections on file
- 39
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Vista Ridge Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, aphasia, severe mental illness, and significant ADL deficits told a psychologist that a family member was touching her inappropriately in a sexual manner. The psychologist informed the Admin, who acknowledged that reporting abuse allegations to the state was her responsibility. Despite a written Abuse Prevention Program requiring immediate reporting of all alleged abuse to the state agency and submission of written investigative findings, the Admin did not file an incident in TULIP or notify the state, stating she did not believe it was abuse because the resident said the family member always did it and thought it was funny and did not explicitly say it was without consent.
A resident with moderate cognitive impairment, aphasia, depression, and anxiety reported to a psychologist that a family member had been touching her vaginal area under her clothing without consent. The psychologist informed the SW, who documented the allegation and notified APS, police, and facility leadership, including the DON and administrator. Staff interviews confirmed awareness of the allegation and that supervised visitation was implemented, but review of the state TULIP system showed no report submitted. The administrator, who acknowledged responsibility for state reporting, stated she investigated but did not consider the incident abuse and therefore did not report it, despite facility policy requiring immediate reporting of all alleged abuse to the state agency.
A resident with aphasia, moderate cognitive impairment, severe mental illness, and multiple ADL deficits reported to a psychologist that a family member had been touching her vaginal area under her clothing without consent. The psychologist informed the SW, who documented the allegation and notified APS and police, and the resident requested supervised visitation rather than criminal charges. The RN, SW, psychologist, ADON, and DON all acknowledged awareness of the allegation, and the facility’s abuse policy required immediate reporting of alleged abuse and submission of written investigation findings within five working days. The administrator conducted an internal investigation but, based on her belief that the conduct was not abuse, did not submit an incident report or the investigation findings to the State Survey Agency, resulting in a failure to report as required.
Surveyors found that several residents with cognitive impairment, muscle weakness, and fall risk did not have their call lights within reach, despite care plans and facility policy requiring accessibility. Observations showed call lights placed on the floor, on chairs, or otherwise out of reach, and staff interviews confirmed the expectation that call lights should be accessible and checked during rounds.
A resident with cognitive impairment, muscle weakness, and seizures was found with a bolster mattress on the bed without a physician order or care plan intervention for its use. Staff, including an LVN and the Interim DON, were unaware of the need for a physician order, and facility policy required such orders for physical restraints.
Three residents requiring respiratory care had their nebulizer and CPAP masks improperly stored unbagged when not in use, despite care plans and physician orders specifying respiratory therapy. Nursing staff acknowledged responsibility for ensuring proper storage but admitted to lapses, and the DON confirmed expectations for bagging masks were not consistently met.
A resident with severe cognitive impairment, a history of aspiration pneumonia, and a physician-ordered pureed diet was left unsupervised during a meal and ate a regular cookie offered by another cognitively impaired resident. Despite multiple staff being present in the dining room, no one intervened or noticed the resident eating outside her prescribed diet, leading to coughing episodes. The resident's care plan required assistance and supervision with eating, but these interventions were not followed, and staff were unclear about their monitoring responsibilities.
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in the handling and maintenance of respiratory equipment. A resident with chronic pulmonary embolism had a nasal cannula improperly stored and not changed weekly, and lacked an 'Oxygen in Use' sign. Another resident with COPD had a nasal cannula not bagged when not in use. A third resident with sleep apnea had a BiPAP mask that was not cleaned or bagged properly, increasing the risk of contamination.
A facility failed to review and update a resident's care plan quarterly, as required. The resident, who was cognitively intact and had multiple health conditions, had not been involved in a care plan meeting since the previous year. Staff interviews revealed that a system changeover prevented access to previous records, and the facility's policy on involving residents in care planning was not followed.
A resident, who was cognitively intact and had multiple diagnoses, was not included in his care plan conference, and his involvement was not documented. Interviews revealed that the resident had not participated in a care plan meeting since the previous year, despite expressing concerns about his medication and discharge plan. Facility staff cited a system changeover as the reason for the lack of access to previous records, and the facility's policy encourages resident participation in care plan development.
A CMA left a computer unlocked and unattended on a medication cart, exposing resident information on Hall 300. The lapse occurred while the CMA assisted a resident, allowing others to potentially view sensitive data. The CMA admitted awareness of the policy to lock the computer but forgot in this instance.
A resident with dementia and chronic kidney disease was found with urine-stained sheets that had not been changed, leading to an unsanitary living condition. The resident reported that staff typically did not change his sheets, and he had to wait for them to dry before using the bed. Interviews revealed that the CNA was unaware of the need to change the linens, and the facility's policy required linens to be changed if soiled to prevent infection control issues.
A medication cart on Hall 300 was left unlocked and unattended, allowing easy access to medications while a CMA assisted a resident. Despite knowing the protocol, the CMA forgot to lock the cart, which was against the facility's policy. This incident occurred in the presence of residents and a housekeeper, posing a risk of unauthorized access.
The facility failed to maintain an infection control program, leading to inadequate PPE usage and hand hygiene by two CNAs. This placed residents at risk of infection, as the CNAs did not follow proper protocols while caring for COVID-19 positive residents.
Failure to Report Alleged Sexual Abuse According to Facility Policy
Penalty
Summary
The facility failed to implement and follow its written abuse prevention policies and procedures when a resident reported sexual abuse by a family member. A psychologist reported to the Administrator that the resident stated her family member was touching her inappropriately in a sexual manner. The resident had a BIMS score of 10, indicating moderate cognitive impairment, unclear speech, and usually understood others, and required substantial/maximal assistance with ADLs including oral hygiene, toileting hygiene, showering, dressing, personal hygiene, and bed mobility. The resident’s care plan, initiated the day after the reported outcry, documented that she had voiced concerns to staff about the conduct of her family member during visits, and included care areas such as ADL deficit, severe mental illness with antidepressant and anti-anxiety medications, communication problems (aphasia), fall risk, and mood and psychosocial problems with APS and psychological services involved. Despite the facility’s Abuse Prevention Program policy, which required all alleged violations involving abuse to be immediately reported (within two hours for abuse) to the state licensing/certification agency and thoroughly investigated with written findings submitted within five working days, the Administrator did not report the allegation to the state. The Administrator stated that she considered it her responsibility to call the state regarding allegations of abuse or neglect, acknowledged that the psychologist had reported the resident’s allegation to her, and stated she did not report it because the resident said the family member always did this and thought it was funny, and the resident did not tell her it was without consent. The Administrator reported that she conducted an investigation but did not think it was abuse, so she neither reported the allegation nor submitted the investigation to the state. Record review of TULIP showed no incident report related to this allegation, confirming the failure to report as required by the facility’s policy and federal requirements.
Failure to Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of sexual abuse to the State Survey Agency as required by federal regulations and the facility’s own Abuse Prevention Program. A female resident with a history of aphasia following cerebral infarction, dysphagia, major depressive disorder, and generalized anxiety disorder, and with a BIMS score of 10 indicating moderate cognitive impairment, reported that her family member (FM) had been touching her vaginal area. According to the police report, the resident stated the FM placed his hand under her clothing, making direct contact with her vaginal area without her consent. The resident’s care plan documented that she had voiced concerns about the FM’s conduct during visits and that visits were to be supervised in common areas during daytime hours when administration was present. Record review showed that on the date of the allegation, the psychologist was informed by the resident that the FM was touching her inappropriately and the psychologist notified the social worker (SW), police, and Adult Protective Services (APS) the same day. Progress notes documented that the SW met with the resident to clarify concerns, that APS and police were notified, and that the SW informed the DON, administrator, and charge nurse. Interviews with the RN, SW, psychologist, ADON, DON, and administrator confirmed that facility leadership was aware of the allegation of inappropriate sexual touching by the FM and that internal steps were taken to ensure supervised visitation and to notify law enforcement and APS. However, review of the TULIP reporting system showed no incident report submitted to the State Survey Agency (HHSC) regarding this allegation. The administrator acknowledged in interviews that she was responsible for reporting allegations of abuse or neglect to the state and that she did not report this allegation. She stated she had conducted an investigation but did not believe the situation constituted abuse because the resident told her the FM “always did this and he thought it was funny” and did not explicitly state to her that it was without consent. The facility’s Abuse Prevention Program policy required that all alleged violations involving abuse be reported immediately, but not later than two hours, to the state licensing/certification agency and other appropriate agencies, and that all reports of resident abuse be promptly reported to local, state, and federal agencies and thoroughly investigated. Despite this policy and staff recognition that such allegations should be reported to the state, the allegation involving this resident was not reported to the State Survey Agency.
Failure to Report Sexual Abuse Allegation Investigation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report the results of an abuse investigation to the State Survey Agency within the required timeframe, as mandated by federal and state requirements and the facility’s own Abuse Prevention Program. A resident with aphasia following a stroke, dysphagia, major depressive disorder, generalized anxiety disorder, and moderate cognitive impairment (BIMS score of 10) reported concerns about the conduct of her family member (FM) during visits. Her care plan documented that she had voiced concerns about the FM’s conduct, that visits were to be supervised in common areas during daytime hours when administration was present, and that police had been notified. The care plan also reflected multiple care areas, including ADL deficits, severe mental illness with antidepressant and anti-anxiety medications, communication problems, fall risk, and mood/psychosocial problems with APS and psychological services involved. According to the police report and facility progress notes, the resident told the psychologist that the FM had been touching her vaginal area, placing his hand under her clothing and making direct contact with her vaginal area without her consent. The psychologist notified the social worker (SW), who then met with the resident to clarify concerns and documented that APS and the police department were notified. The resident stated she did not want to press criminal charges but wanted supervised visitation. Interviews with the RN, SW, psychologist, ADON, and DON confirmed that the resident had reported inappropriate touching by the FM, that law enforcement and APS were contacted, and that supervised visitation parameters were put in place. The DON and ADON both stated that allegations of abuse or neglect should be reported to the state and that the administrator was responsible for making such reports. Record review of the facility’s investigation showed that the administrator was notified by the SW of the allegations and that the administrator interviewed the resident. The administrator acknowledged that she conducted an investigation but did not report the allegation or the investigation findings to the State Survey Agency. She stated she did not think it was abuse because the resident told her the FM “always did this and he thought it was funny” and did not, in the administrator’s view, clearly state it was without consent. TULIP review showed no incident report submitted regarding this allegation. This inaction conflicted with the facility’s Abuse Prevention Program, which requires all alleged violations involving abuse to be reported immediately (within two hours if involving abuse) and that a written report of the investigation findings be provided to appropriate agencies within five working days of the incident.
Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that the nurse call system was accessible for residents to call for staff assistance, as required. Observations on multiple halls revealed that the call lights in the rooms of seven residents were not within their reach. In several cases, the call lights were found hanging over chairs, on the floor, on top of wheelchairs, or behind beds, making it impossible for the residents to access them when needed. These findings were confirmed during observations conducted by surveyors on the same day. The residents affected had significant medical histories, including muscle weakness, lack of coordination, repeated falls, and varying levels of cognitive impairment as indicated by their BIMS scores. Their care plans specifically included interventions to ensure that call lights were within reach due to their high risk for falls and need for assistance with activities of daily living (ADLs). Despite these documented needs, the call lights were not positioned appropriately at the time of the survey. Interviews with nursing staff, including LVNs and RNs, confirmed that the expectation was for call lights to be within reach of residents and that staff were supposed to check this during their rounds. Staff acknowledged that call lights could be moved or knocked off by residents, but also stated that they had procedures, such as using clips, to keep them accessible. The interim DON reiterated the expectation for call lights to be within reach and for staff to check their placement during rounds. Review of the facility's policy also confirmed the requirement for call lights to be accessible to residents when in bed.
Failure to Obtain Physician Order for Bolster Mattress Used as Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. Specifically, a resident with a history of lack of coordination, muscle weakness, and seizures was observed with a bolster mattress on the bed. Review of the resident's care plan and physician orders revealed that there was no physician order for the use of the bolster mattress, and the care plan did not include this intervention. The resident required total assistance with activities of daily living and was at risk for falls and seizures, but the use of the bolster mattress was not documented as an intervention in the care plan. During interviews, staff members, including an LVN and the Interim DON, were unsure whether a physician order was required for the bolster mattress and confirmed that no such order was present. The facility's policy indicated that physical restraints should only be used when warranted by medical symptoms and with appropriate orders. The lack of a physician order for the bolster mattress constituted a failure to ensure the resident's environment was free from unnecessary physical restraints.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required respiratory equipment, as evidenced by improper storage of nebulizer and CPAP masks. Observations revealed that two residents had nebulizer masks left unbagged—one on a nightstand and another in a drawer—while a third resident's CPAP mask was also found unbagged on a nightstand. Interviews with nursing staff confirmed that it was their responsibility to ensure masks were bagged after use to prevent infection, but they admitted to forgetting or needing to remind residents to do so. The interim DON stated that masks should be air dried and then bagged, but acknowledged that sometimes residents removed the masks from the bags. Record reviews indicated that all three residents had relevant diagnoses requiring respiratory care, such as chronic cough, shortness of breath, COPD, and sleep apnea, and each had care plans and physician orders specifying the use of respiratory equipment. The facility's own policy on infection prevention for respiratory therapy equipment was not followed, as the masks were not properly stored when not in use, contrary to professional standards and the residents' care plans.
Failure to Provide Adequate Supervision During Meal Service for Resident on Pureed Diet
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of aspiration pneumonia, oropharyngeal dysphagia, and a physician-ordered pureed diet was not provided adequate supervision during a lunch meal. The resident, who required assistance with eating and was known to be noncompliant with her diet due to her cognitive status, was seated at a table with another cognitively impaired resident who was on a regular diet. No staff were directly supervising or assisting her at the time, despite five staff being present in the dining room. During the meal, the resident was able to feed herself and was observed to take a regular sugar cookie offered by the other resident at her table. She ate the cookie, which was not consistent with her prescribed pureed diet, and began coughing several times before finishing it. Staff in the dining room did not notice the incident or intervene, and the resident was able to finish the cookie and her meal without further immediate incident. The resident's care plan and CNA Kardex both indicated she required assistance and supervision with eating, and her history included previous episodes of aspiration and pneumonia related to swallowing difficulties. Interviews with staff revealed that the resident was known to take food from others and from snack carts, and that staff had previously voiced concerns about her access to non-pureed foods. The seating arrangement in the dining room did not account for her supervision needs, and staff were unclear about their responsibilities for monitoring residents with special dietary requirements. The incident was not immediately recognized or addressed by staff present, and the facility did not have a specific policy on accident hazards related to dining supervision at the time of the event.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in the handling and maintenance of respiratory equipment. Resident #1, a male with chronic pulmonary embolism, was observed with a nasal cannula improperly stored on the bed's grab bars and not bagged when not in use. The nasal cannula and humidifier had not been changed weekly as required, with the last change dated over a week prior. Additionally, there was no 'Oxygen in Use' sign outside the resident's door, which is necessary for safety precautions. Resident #2, a female with chronic obstructive pulmonary disease, was found with a nasal cannula not bagged when not in use, as it was left on the bed. The resident was unaware of the need to bag the nasal cannula to prevent contamination. This oversight in proper storage and handling of the nasal cannula could lead to potential respiratory infections. Resident #3, a female with sleep apnea, had a BiPAP mask that was not bagged and was found with a white substance on it, indicating it was not cleaned properly. The mask was stored in a drawer without a bag, increasing the risk of contamination. The resident sometimes refused to wear the BiPAP due to noise, and staff did not ensure the mask was cleaned and stored correctly after use.
Failure to Review and Update Resident Care Plan
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, for one resident. This deficiency was identified during interviews and record reviews, which revealed that the care plan for an 86-year-old male resident with diagnoses including dementia, chronic kidney disease stage 3, and benign prostatic hyperplasia was not reviewed or updated quarterly. The resident, who was cognitively intact and required assistance for activities of daily living, had not been involved in a care plan meeting since the previous year, despite expressing concerns about his medication list and discharge plan. Interviews with facility staff, including the social worker, DON, and administrator, indicated that a system changeover had occurred, preventing access to previous resident records and care plan conferences. The social worker and DON were unsure of the exact date of the last care plan meeting, and the administrator acknowledged the inability to access records prior to the system change. The facility's policy on care planning emphasized the importance of involving the resident and their representatives in care plan development and revisions, but this was not adhered to in this case.
Resident Excluded from Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident had the right to participate in the development and implementation of his person-centered plan of care. This deficiency was identified for a resident who was cognitively intact, as indicated by a BIMS score of 13, and had diagnoses including dementia, chronic kidney disease stage 3, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident was not included in his Care Plan Conference, and the most recent care plan did not document his involvement. Interviews revealed that the resident expressed a desire to obtain a copy of his medication list and discuss his discharge plan, as he had not been involved in a care plan meeting since the previous year. Interviews with facility staff, including the Social Worker, DON, and Administrator, indicated that there was uncertainty about the last care plan meeting date due to a system changeover that affected access to previous records. The Social Worker acknowledged that the resident had not had a care plan conference this year and planned to schedule one soon. The Administrator confirmed the inability to access previous records due to the system change and stated that they were working on completing care plans for the current quarter. The facility's policy encourages resident participation in care plan development, but this was not adhered to in this case.
Confidentiality Breach During Medication Pass
Penalty
Summary
The facility failed to protect the confidentiality of personal health care information for residents on Hall 300. During an observation, it was noted that the computer on Medication Cart 1 was left unlocked and unattended by a Certified Medication Aide (CMA B) while she assisted a resident in a room. This lapse occurred for approximately two minutes, during which time residents and a housekeeper passed by the unlocked computer, which displayed the names and medication information of residents on the hall. CMA B, who had been employed at the facility for four months, acknowledged that she was aware of the requirement to lock the computer but forgot to do so in this instance. The facility's policy on resident rights, revised in October 2022, emphasizes the importance of privacy and confidentiality, which was compromised in this situation.
Failure to Maintain Sanitary Environment for Resident
Penalty
Summary
The facility failed to provide a sanitary environment for a resident, who was one of four residents reviewed for environmental conditions. The resident, an 86-year-old male with diagnoses including dementia, chronic kidney disease stage 3, and benign prostatic hyperplasia, was found to have a bed with urine-stained sheets that had not been changed. The resident reported that he had wet the bed the previous night, and the sheets had not been changed, leaving the mattress wet and the sheets nearly dry. The resident expressed that staff typically did not change his sheets, and he often had to wait for them to dry before using the bed. Interviews with staff revealed that the certified nursing assistant (CNA) responsible for the resident's hall was unaware of the need to change the linens, as she had just started her shift. The facility's policy indicated that CNAs were responsible for changing linens on shower days or as needed if they were soiled. The administrator confirmed that linens should be changed if soiled to prevent infection control issues or skin breakdown. The facility's policy on resident rights emphasized the right to a dignified existence, which includes a safe, clean, and comfortable environment.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments on Hall 300, as observed on April 16, 2024. Medication Cart 1 was found unlocked and unattended, with all drawers accessible, while a Certified Medication Aide (CMA) was assisting a resident in a nearby room. This lapse in protocol occurred despite the presence of residents and a housekeeper in the vicinity, posing a risk of unauthorized access to medications. The CMA involved had been employed at the facility for four months and acknowledged awareness of the requirement to lock the medication cart when not in sight. However, she admitted to forgetting to lock the cart while attending to a resident's needs. The facility's policy, revised in April 2019, clearly states that unlocked medication carts should not be left unattended, highlighting a breach in adherence to established procedures.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, which resulted in inadequate PPE usage and hand hygiene practices by two CNAs. CNA A and CNA B did not wear the necessary PPE while repositioning a COVID-19 positive resident and delivering breakfast trays to another COVID-19 positive resident. Additionally, CNA A did not perform hand hygiene while delivering and picking up breakfast trays from residents on the 300 hall, including both COVID-19 positive and negative residents. Resident #1, who had multiple diagnoses including dementia and respiratory failure, required substantial assistance with bed mobility. CNA A and CNA B entered her room with only N95 masks, failing to wear gowns, gloves, and face shields as required. They did not perform hand hygiene after repositioning her. Similarly, Resident #2, who was cognitively intact but required assistance with eating, was visited by CNA A who only wore a N95 mask and did not perform hand hygiene after delivering her breakfast tray and milk. The facility's Director of Nursing (DON) confirmed that staff were aware of the COVID-19 positive residents and the required PPE protocols. However, the PPE carts on the 300 hall were inadequately stocked, and the CNAs did not inform the nurses about the shortage. The DON acknowledged that the failure to wear proper PPE and perform hand hygiene placed residents at risk of infection. Interviews with the CNAs revealed they were aware of the PPE requirements and hand hygiene protocols but did not follow them due to the lack of supplies and oversight.
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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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