Williamsburg Village Healthcare Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Desoto, Texas.
- Location
- 941 Scotland Dr, Desoto, Texas 75115
- CMS Provider Number
- 675756
- Inspections on file
- 94
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 34 (5 serious)
Citation history
Health deficiencies cited at Williamsburg Village Healthcare Campus during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and known exit‑seeking behavior twice eloped from a secured unit after staff failed to maintain functional door and window alarms and to implement effective monitoring. In the first incident, a floor technician saw someone leaving through a back door whose alarm had been turned off so staff could use it for breaks, but he did not follow or redirect the individual; the resident was later found off‑site by law enforcement. Despite this, the resident’s elopement assessment rated him low risk and there was no documented one‑to‑one or 15‑minute monitoring. Days later, the same resident eloped again through a window in his former room where the alarm had been removed and safety brackets broken, allowing the window to open wide enough for him to exit without staff noticing; he was later located at a hospital being treated for chest pain. These events show that nonfunctioning alarms, unsecured egress points, and insufficient supervision directly led to repeated elopements.
A resident admitted with cellulitis, HTN, wound infection, and risk of malnutrition, and assessed with moderate cognitive impairment and need for supervision with most ADLs, chose to leave AMA to a community shelter after refusing care, medications, and wound treatment. The SW documented informing the resident that leaving would be AMA and that medications could not be sent, and nursing documented that leadership was aware and the resident left with belongings. However, the physician discharge summary left the condition upon discharge, prognosis, and discharge diagnosis sections blank and did not include special instructions, precautions, or risks related to the AMA discharge. The EHR contained no completed AMA form signed by the resident or staff, and interviews confirmed that required AMA procedures and written discharge instructions outlined in facility policy, including execution of AMA forms, were not documented for this discharge.
A resident with severe cognitive impairment and multiple comorbidities fell in a hallway after becoming agitated during redirection, striking his head and torso against a handrail and sustaining a facial abrasion. The assigned LVN reported verbally that the resident was ambulatory and at baseline afterward but did not document vitals, neuro checks, or a post-fall assessment in the EHR, and did not notify the MD, DON, ADON, weekend supervisor, or the resident’s family at the time of the incident. Later that day, family observed a bloody bandage and mental status changes, learned of the fall only after questioning the LVN, and then signed the resident out and transported him to the hospital, where he was found to have rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. Subsequent interviews and record review showed that required immediate assessment, documentation, and notification protocols for incidents and changes in condition were not followed.
A resident with severe dementia and known fall and wandering risks fell after becoming agitated during redirection, striking his head and torso on a hallway rail and sustaining a visible facial abrasion. The assigned LVN helped the resident up and applied a bandage but did not complete or document required post‑fall assessments such as vitals, head‑to‑toe exam, neuro checks, or pain assessment, and did not notify the MD, DON, ADON, weekend supervisor, or the family. Later that day, the family noticed the bloody bandage and a change in the resident’s mental status, questioned the LVN, and then signed the resident out and transported him to the hospital, where he was diagnosed with rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. Facility records and staff interviews confirmed that the mandated assessments and notifications were not performed or documented at the time of the fall.
A resident with severe cognitive impairment, dementia, and fall/wandering risk, who required supervision and assistance with mobility and ADLs, was observed roaming in and out of rooms and was redirected by an LVN. During redirection, the resident became aggressive, attempted to hit the nurse, lost balance, and fell against a handrail, sustaining a noted abrasion to the temple. Later that day, at the family’s request, the resident was sent to the hospital for change of condition and was diagnosed with rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. Despite facility policy and federal requirements mandating prompt reporting of alleged abuse/neglect incidents and events resulting in serious bodily injury to the Administrator and appropriate agencies within specified timeframes, the DON and Administrator did not report the incident to the State agency or other required authorities, constituting a failure to timely report a serious, reportable event.
A resident with severe cognitive impairment, multiple comorbidities, and identified fall and wandering risks experienced a witnessed fall after becoming aggressive during redirection, striking a handrail and sustaining a visible abrasion. The primary LVN did not report the fall to the Administrator or notify the MD or family, and the subsequent transfer note to the hospital cited a change in condition (N/V) without linking it to the fall. Hospital evaluation revealed multiple traumatic injuries, including rib fractures, adrenal hematoma, and a grade 3 liver laceration. Despite being informed of the serious injuries and that the fall occurred in the facility, the Administrator and DON did not promptly initiate or document a thorough investigation in accordance with the facility’s abuse/neglect investigation policy.
A resident with dementia, kidney failure requiring dialysis, and impaired mobility was left unattended and unsupervised in a facility transport van for several hours in cold weather after returning from a dialysis appointment. The resident, who used a wheelchair and lived on a memory care unit, was later discovered buckled into a van seat with his wheelchair stored in the back, while temperatures were in the 30s°F. Staff interviews revealed that the resident was not promptly accounted for on the unit, that a CNA eventually noticed movement in the van and found the resident inside, and that nursing staff doubted the resident could have independently exited the secured unit, navigated outside, loaded his wheelchair, and buckled himself in. The resident reported that the driver had left him in the van, and the medical record lacked documentation of the incident or subsequent assessments, contributing to a finding of Immediate Jeopardy related to inadequate supervision and accident hazard prevention.
Multiple residents with pressure ulcers, end-stage skin failure, and a Kennedy terminal ulcer did not consistently receive ordered wound care, as wound treatment records showed numerous missed entries and progress notes lacked documentation of care. One resident with severe cognitive impairment and multiple stage 4 and unstageable foot and heel ulcers had many days where prescribed cleansing and dressings were not provided. Another resident with sacral end-stage skin failure had daily and PRN wound orders that were repeatedly marked as missed on the treatment record. A third terminal resident with a Kennedy ulcer on the ischium also had ordered Dakin’s-based dressings missed on several days. Observations confirmed the presence of wounds and that when the wound care nurse did perform treatments, they followed ordered procedures, but interviews revealed that floor nurses were responsible for wound care when the wound nurse was off and that the wound nurse had not monitored treatment administration records, contributing to unaddressed missed treatments.
A resident with dementia, severe cognitive impairment, and impaired mobility who used a wheelchair and received thrice-weekly dialysis was discovered in the facility’s transport van late in the evening after having returned from dialysis earlier that afternoon. Staff reported that the resident was found seated and belted in the van, and the resident stated that the driver had left him there, while the driver and Administrator asserted the resident had been returned to the unit and later made his way back to the van. An LVN stated she did not believe the resident was physically or cognitively capable of independently leaving the locked unit, navigating to the van, loading his wheelchair, and buckling himself in. The incident was not documented in the EHR, and the Administrator did not report the alleged neglect to the state agency as required by the facility’s abuse/neglect policy, which mandates timely reporting of reportable allegations to regulatory authorities.
A resident with stroke-related weakness and ESRD, care planned for Hoyer lift transfers with two-person assist, was manually transferred from bed to wheelchair by several CNAs instead of using the mechanical lift. During the transfer, the resident’s leg twisted, causing immediate severe pain, but she was still transported to dialysis, where she arrived crying, with a Hoyer sling under her and 10/10 left leg pain. Dialysis staff reported the resident consistently stated that aides at the facility had twisted her leg during the transfer, and she was sent to the ED, where imaging showed an acute comminuted distal femur fracture. One CNA admitted the lift was reportedly broken and that they used a sling and draw sheet with multiple staff, while other CNAs gave conflicting accounts and did not report the resident’s pain to an LVN, contrary to the care plan and facility policies on mechanical lifts and change of condition.
A resident with impaired mobility and a care plan requiring Hoyer lift transfers was manually transferred from bed to wheelchair by multiple CNAs, after which she immediately reported severe leg pain and stated that staff had twisted her leg. She was transported to dialysis still in pain, where dialysis staff observed her crying, unable to move her leg, and still in a Hoyer sling, and she repeatedly told them that nursing home staff had hurt her during the transfer. Hospital evaluation revealed an acute distal femur fracture. Despite the resident’s consistent allegations to family and dialysis staff that the injury occurred during a transfer at the facility and the facility’s policy requiring reporting of all alleged abuse/neglect to the State, the DON and Administrator concluded the incident was not reportable, believing it occurred at the dialysis center, and did not report the allegation to the State Survey Agency within the required timeframe.
A resident who was care planned for Hoyer lift transfers with two‑person assistance was manually transferred from bed to wheelchair by multiple CNAs, after which she immediately reported severe left leg pain. She was transported to dialysis, where staff found her crying in pain with a Hoyer sling still under her, and she consistently reported that nursing home aides had twisted her leg during the transfer. Dialysis staff did not move her to a dialysis chair due to pain and arranged EMS transport; hospital imaging showed an acute distal femur fracture. Despite multiple consistent accounts from the resident and dialysis staff that the injury occurred during a facility transfer and that the resident had reported pain before leaving, the DON did not verify events with the dialysis center, did not interview all involved staff at the time (including the assisting CNA), and could not produce documented staff statements, while the Administrator asserted the event was not reportable because it allegedly occurred at dialysis. The facility’s actions and omissions show it failed to conduct and document a thorough investigation of an allegation of neglect and injury as required by its abuse/neglect policy.
Two residents with severe cognitive and physical impairments did not receive timely incontinence care, resulting in them being found in heavily soiled briefs and linens. The CNA assigned did not follow proper perineal care procedures, including failing to cleanse the perineal area and not changing gloves after a bowel movement. Nursing staff acknowledged the expectation for incontinence rounds every two hours but could not confirm compliance, and training records lacked specific guidance on the required frequency of care.
Two residents with significant medical conditions did not receive proper incontinence care when a CNA failed to perform hand hygiene and change gloves between tasks, and did not cleanse the peri area as required. Despite prior training and facility policy, the CNA used the same gloves after handling soiled linens and before applying clean briefs, actions confirmed by interviews with nursing leadership and staff.
A resident with severe cognitive impairment and multiple diagnoses was discharged to another facility without a completed discharge summary, as required. Nursing staff did not complete the summary due to unfamiliarity with a new system, and facility leadership was unaware of the omission. Only a progress note and physician discharge summary were present, and the facility's policy for discharge documentation and notification was not fully followed.
Two residents with severe cognitive impairment and behavioral health needs were physically harmed in separate altercations with other residents. In one case, a resident was struck with a ruler and stabbed with a pen by a roommate, resulting in lacerations and emotional distress. In another, a resident was pushed by another resident, causing a hip and wrist fracture that required hospitalization and surgery. Staff and record reviews confirmed that the facility did not prevent these incidents, leading to significant harm.
A resident with severe dementia and a history of wandering eloped from the facility by breaking a window, despite being on 15-minute checks. The resident was found by police exhibiting psychotic behaviors and was transported to the hospital for evaluation. Staff interviews and records confirmed that required supervision was in place, but the resident was able to leave undetected between checks.
Two residents with severe cognitive impairment and incontinence did not receive timely incontinence care as required by their care plans, resulting in prolonged periods without changing, double briefing, and soiled bedding. Staff interviews confirmed knowledge of protocols for two-hour rounding and single brief use, but these were not consistently followed.
A resident with multiple pressure ulcers did not receive wound care as ordered by the physician due to a delay in entering treatment orders into the electronic system, resulting in missed or undocumented wound care treatments. Staff interviews and record reviews confirmed that the orders were not promptly entered or followed, leading to a lapse in the resident's prescribed wound care regimen.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed enteral feedings on several occasions, as documented in the MAR. Nursing staff and the DON confirmed the missed feedings and were unable to provide documentation or reasons for the omissions, despite facility policy requiring prompt implementation and documentation of physician orders.
Staff failed to follow infection control protocols by not performing required hand hygiene during incontinence and wound care for two residents with severe cognitive impairment and complex medical needs, including a stage 4 pressure ulcer. CNAs and an RN were observed skipping handwashing before, during, and after care, handling both soiled and clean items with the same gloves, and not disinfecting surfaces used for wound care supplies, despite facility policies and reported training.
The facility did not ensure that residents were seen by a physician at the required intervals, with all face-to-face visits being conducted solely by a nurse practitioner rather than alternating with the physician as required. Several residents with complex medical needs did not have documented physician visits in their clinical records, and the attending physician acknowledged falling behind on these responsibilities.
A resident with dementia and multiple chronic conditions was not administered her prescribed morning medications on two consecutive days. Staff failed to make additional attempts, document refusals, or notify the physician as required by facility policy, resulting in missed doses of essential medications and lack of appropriate follow-up.
Two residents were prescribed Austedo, a medication for involuntary movements, without documented evidence or formal diagnosis of tardive dyskinesia or other movement disorders. AIMS assessments and nursing notes did not support the need for the medication, and staff interviews revealed a lack of awareness regarding movement issues or the rationale for the prescription. The facility's actions did not align with its policy requiring formal diagnosis and interdisciplinary review before initiating such treatment.
A resident with Alzheimer's disease and significant mobility limitations was found with her call light on the floor and out of reach, despite her care plan requiring it to be accessible due to fall risk. Staff interviews confirmed the expectation that call lights should always be within reach, but this was not ensured during the incident.
A resident with Alzheimer's disease and esophagitis, identified as a fall risk and requiring substantial assistance, did not have prescribed fall prevention interventions implemented as outlined in her care plan. Observations showed the bed was not in the lowest position, the fall mat was not in place, and bed rails were not raised. Staff interviews revealed lapses in following and understanding the care plan interventions.
A resident with Alzheimer's disease and esophagitis, requiring total assistance with eating and on a puree diet, was not provided with feeding assistance, resulting in an untouched meal. The CNA attempted to feed the resident but did not report the missed meal to the LVN, who was unaware until later. Facility policy requiring notification to nursing staff when food intake is low was not followed.
A resident with severe cognitive impairment was injured in an altercation with another resident who pushed her, causing a hip fracture. The second resident, known for verbal aggression and paranoia, was not adequately monitored or managed, leading to the incident. Staff intervened, but the injury had already occurred.
A resident's morphine pills were misappropriated by the ADON, who altered the medication count sheet to show fewer pills than were initially present. The resident, with a history of cancer and moderate cognitive impairment, was due for a morphine dose, but the pills were missing from the cart. The ADON was suspended pending investigation.
A resident with breast cancer missed four doses of the prescribed cancer medication Ibrance due to the facility's failure to administer it as ordered. The DON cited delivery issues from a specialty pharmacy but confirmed there was no valid reason for the missed doses, highlighting the importance of maintaining therapeutic blood levels.
The facility failed to provide adequate personal hygiene care for three residents, leading to deficiencies in their grooming and bathing routines. A resident with severe cognitive impairment was not consistently shaved, despite expressing a desire for facial hair removal. Another resident, legally blind and requiring full assistance, was observed with unwanted facial hair, and there was no record of her being shaved. Additionally, a resident with cognitive impairments did not receive consistent showers, as documented in the facility's records. Staffing and scheduling issues contributed to these deficiencies.
The facility's North and South kitchens failed to meet food safety standards. In the North kitchen, several food items were not labeled or dated, risking foodborne illness. In the South kitchen, Nutrition Aides with facial hair did not wear beard guards while handling food and clean dishes, due to unavailability. These actions violated facility policies and the Federal Food Code, potentially endangering residents.
A resident's dignity was compromised when their catheter urine collection bag was observed without a privacy cover, lying on the floor. Despite the resident's discomfort, staff were unaware of the issue, which violated the facility's policy on catheter care. Interviews with staff highlighted a lack of communication and adherence to privacy protocols.
A resident with legal blindness and muscle wasting was found without access to her call light, as it was placed on the floor behind her and under the bed. The resident, who required substantial assistance with ADLs, reported yelling for help or waiting for staff to check on her. An LVN was unaware of why the call light was not within reach, contrary to the facility's policy.
A facility failed to ensure a diabetic resident's wound was covered as per physician orders, leading to an uncovered and bleeding wound. The resident, with severely impaired cognition, had a dressing dated a week earlier found in their sock. Nursing staff were unaware of the dressing's removal, and an RN admitted to using an old dressing without updating records. The DON confirmed expectations for staff to follow orders, but inconsistent training and documentation were noted.
A resident with an indwelling catheter was at risk of urinary tract infections due to improper catheter care. The catheter urine collection bag was repeatedly found on the floor or tangled, causing discomfort and potential backflow of urine. Nursing staff failed to adhere to proper protocols, and the DON was not informed of these issues, highlighting a communication breakdown within the facility.
A resident experienced a significant weight loss of 15.51% over 30 days due to inadequate monitoring and intervention by the facility. Despite being on a therapeutic diet, the resident's decline in appetite and food pocketing were not communicated to the physician or dietitian. Discrepancies in recorded weights were not promptly addressed, leading to a lack of timely interventions.
The facility failed to securely store medications, as observed with an unsecured medication cart and two residents having unauthorized medications in their rooms. One resident had arthritis pain cream at his bedside without a physician's order, while another self-administered pain cream due to delayed staff response. The facility's policy requires medications to be accessible only to authorized personnel.
A resident with severe cognitive impairment and specific dietary needs was served inappropriate food items, including whole potato chips, a whole piece of cake, and thin liquids, instead of the prescribed pureed diet and nectar thickened liquids. The deficiency was observed during a lunch meal, and staff failed to recognize and adhere to the resident's dietary requirements, leading to potential risks of aspiration and choking.
A resident with hypertension and hemiplegia was found without a call light cord in their room, despite their care plan indicating the need for one due to fall risk. Staff interviews revealed a lack of awareness and documentation regarding the missing call light, and the facility's policy did not address the need for functioning call lights in rooms.
A facility failed to ensure a resident's bed was made in a timely manner after being sanitized, preventing the resident from lying down. The resident, who was severely cognitively impaired, was observed with an unmade bed that had small puddles of liquid on the mattress. A CNA responsible for the resident's care did not return to wipe down the mattress, assuming it was not an issue. Interviews with staff revealed that leaving the bed uncleaned for an extended period was unacceptable and posed a risk of infection.
A medication cart was found unlocked and unattended near a main entrance, with residents nearby, in a facility. LVN A confirmed the cart belonged to an MA who was down the hall. The MA could not explain why the cart was left unlocked. The DON and Administrator acknowledged staff training on keeping carts locked, as per facility policy.
The facility failed to protect residents from abuse, resulting in an incident where a resident with dementia and behavioral disturbances physically harmed another resident. Despite known aggressive behaviors and auditory hallucinations, the facility did not maintain adequate supervision or interventions, leading to the injured resident being diagnosed with a maxillary fracture and epistaxis.
The facility failed to maintain a clean and safe environment for six residents, with issues including improper disposal of soiled briefs, stained privacy curtains, and dusty ceiling vents. Staff acknowledged the deficiencies and the potential risks of contamination and an unsafe environment for the residents.
The facility failed to provide timely incontinence care to six residents, leading to issues with personal hygiene and dignity. Residents were found with heavily soaked briefs, some wearing double briefs against policy, and staff interviews revealed a lack of adherence to the facility's policy of checking and changing residents every two hours.
The facility failed to provide necessary wound care for two residents with pressure ulcers according to physician orders. One resident did not receive wound care for two consecutive days, and the responsible LVN was unaware of the missed care. Another resident also missed wound care for two days due to a high workload, and the LVN admitted to signing the treatment record without performing the care. The DON was unaware of these lapses and stated that the nursing staff knew they had to follow physician orders.
The facility failed to ensure that two residents received scheduled showers, leading to gaps in care and potential health risks. Despite care plans and staff responsibilities, inconsistencies in documentation and follow-up resulted in missed showers for both residents.
The facility failed to provide proper respiratory care to a resident by not ensuring the oxygen concentrator and nasal cannula were dated, labeled, and changed weekly, and by delivering oxygen at 2.5 liters per minute instead of the prescribed 2 liters. This placed the resident at risk for inadequate oxygen delivery and possible infection.
Repeated Elopements Due to Disabled Alarms and Inadequate Supervision on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a hazard‑free, secure environment for a cognitively impaired resident on a secured unit, resulting in two elopements. The resident was an adult male with non‑Alzheimer’s dementia, neurocognitive disorder, severe cognitive impairment (BIMS score of 7), and a history of wandering per admission clinicals. His MDS showed he ambulated independently and required moderate assistance with most ADLs. His care plan, revised 04/22/26, identified cognitive loss and exit‑seeking behaviors, with interventions such as redirection and moving him closer to the nurses’ station for monitoring. Despite this, the resident told staff he had been trying to get out of the door every day for 20 days, indicating ongoing exit‑seeking that was not effectively addressed. On the first elopement, at approximately 2:00 a.m. on 04/20/26, the resident was discovered missing from his room and a Code Green was activated. A floor technician reported seeing a man in a gray hoodie exiting the back door around that time. The technician stated the exit door alarm, which should have sounded when opened, had been turned off by someone so staff could go out for breaks without disturbing the facility or getting locked out. Instead of intervening or following the individual he saw leaving, the technician went to inform an aide, and by the time staff searched outside, the resident could not be located. Law enforcement later found and returned the resident around 4:30 a.m. The resident subsequently stated he had been trying the door daily and finally found it unlocked, and that he had walked for 2–3 hours looking for public transportation before encountering officers. Following the first elopement, the resident’s elopement assessment on 04/20/26 scored him as low risk (score 10) with no mental or behavioral issues documented, despite his dementia, history of wandering, and expressed exit‑seeking. The DON later stated that residents with exit‑seeking behaviors were to be placed on 15‑minute checks for 72 hours and, if unresolved, on one‑to‑one supervision until reassessment and psych clearance; however, there was no evidence provided of 15‑minute checks for this resident, and he was not placed on one‑to‑one supervision. On the second elopement, during the overnight shift of 04/23–04/24, staff last observed the resident near the nurses’ station around 12:30 a.m., awake, eating snacks, writing, and later napping on a couch. Around 1:30 a.m., he was found missing, and staff discovered that a window in his previous room was open with part of the window alarm removed and the brackets that should have limited the window opening to 6 inches broken off. Staff reported that the alarm on that window had been removed, so no alert sounded when it was opened. The resident eloped through this unsecured window without staff noticing and was later found at a hospital under another name, being treated for chest pain. These events demonstrate that exit doors and windows were not consistently secured or alarmed as required, and that staff supervision and monitoring interventions were not effectively implemented for a known exit‑seeking, cognitively impaired resident on a secured unit. The facility’s own elopement policy required that alarms and security measures function properly, that residents at risk for elopement be appropriately assessed and care planned, and that staff respond immediately when a resident is missing. In this case, the exit door alarm had been turned off, the window alarm and safety brackets were broken or removed, and the resident’s elopement risk assessment did not reflect his documented history of wandering and exit‑seeking. Staff interviews confirmed that the floor technician did not follow the resident when he saw someone leaving through the back door, and that staff were unaware of the disabled window alarm until after the second elopement. The combination of disabled or nonfunctional alarms, unsecured egress points, and inadequate implementation of monitoring interventions for a resident with dementia and exit‑seeking behaviors led directly to the two elopement incidents that formed the basis of the deficiency.
Failure to Provide Complete Clinical Information and AMA Documentation at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge summary contained an accurate and current description of clinical status and sufficiently detailed, individualized care instructions at the time of discharge against medical advice (AMA). The resident was an adult female admitted with active diagnoses including hypertension, wound infection, and risk of malnutrition, and her baseline care plan documented antibiotic therapy for a wound infection, pneumonia, and UTI, along with monitoring of vital signs, behavioral concerns (talking to herself, moderate elopement risk), and skin issues including a surgical wound and mild risk for pressure ulcers. The MDS reflected moderate cognitive impairment (BIMS score of 8) and a need for supervision with most ADLs. The baseline care plan noted an expectation for discharge to the community but did not include documented interventions related to that discharge. On the day of discharge, progress notes documented that the resident told the social worker she wanted to discharge to a community shelter and was informed that leaving at that time would be an AMA discharge and that medications could not be sent with her; the resident stated she understood and still wished to leave. A subsequent nursing note documented that the resident continued to refuse care, medications, and wound treatment, made arrangements to leave, and left the facility AMA with her belongings, with administration, DON, ADON, and the social worker aware. The physician discharge summary form listed the admission diagnosis of cellulitis of the right lower limb and essential hypertension, identified the discharge type as AMA, and noted that medications were locked in the med room and personal property was taken with the resident, but left the sections for condition upon discharge, prognosis, and discharge diagnosis blank. Further record review showed there was no documentation of special instructions or precautions for ongoing care or of risks associated with discharging AMA in the discharge summary. The electronic health record contained no completed AMA document signed by staff or the resident, despite the facility’s policy requiring AMA forms to be executed when a resident leaves without a physician’s order after being informed of risks and consequences. Interviews with the interim administrator, social worker, NP, and DON confirmed that the resident had been at the facility only a few days, was treated with antibiotics for a leg wound infection, refused care and medications, and chose to leave AMA, and that the social worker was not aware at the time that an AMA discharge form was required. The facility’s written Discharge/Transfer Policy required obtaining a discharge order, notifying the resident and family or representative, providing written discharge instructions/education, and, for AMA discharges, holding a care conference with the treating physician to explain risks and having the resident complete all required AMA forms, steps that were not documented as completed for this resident.
Failure to Notify Physician and Family After Resident Fall With Significant Injuries
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident’s representative after an accident that resulted in injury and had the potential to require physician intervention. The affected resident was an elderly male with severe cognitive impairment, Spanish-speaking only, with diagnoses including anemia, HTN, DM, CKD stage 2, Alzheimer’s dementia, and non-Alzheimer’s dementia. His admission MDS showed a BIMS score of 00, indicating he was unable to complete the interview, and he required supervision or partial assistance with mobility, transfers, toileting, and ADLs. He had a history of wandering and behaviors such as restlessness, disorganized speech, abusive or resistant behavior, and was care planned as at risk for falls and wandering, with interventions including frequent visual checks and redirection. On the morning in question, the resident was reported by the primary nurse (LVN-L) to have been roaming in and out of other residents’ rooms and requiring frequent redirection. According to LVN-L’s later interview, at approximately 7:30 AM the resident became angry when redirected, attempted to swing at the nurse, lost his balance, and fell hard against a hallway handrail, striking his face/head and torso. LVN-L stated he observed an abrasion to the right temple/cheek area, helped the resident off the floor, cleaned and bandaged the area, and claimed he completed vitals, skin, fall, and neuro assessments with regular observations, and that the resident was ambulatory, not in pain, and functioning at baseline. However, the resident’s electronic health record for that date contained no clinical documentation of vital signs, fall assessment, post-fall monitoring, neurological assessments, pain assessments, or any change-in-condition assessments related to the fall. There were also no completed post-fall assessments by LVN-L in the record. Later that day, the resident’s family visited and, at about 5:00 PM, observed a bloody bandage on his face and noted a change in his mental status. During a conference call with LVN-L, the family learned for the first time that the resident had fallen and hit his head on the rail earlier that morning. The family questioned why they had not been notified and expressed concern about increased confusion. LVN-L acknowledged to the family and to the surveyor that he had not notified the responsible party, the physician, the DON, the ADON, or the weekend supervisor about the fall and injury, stating he was not aware he needed to notify the family and that he was busy with 60 residents and ongoing behaviors. He told the family the resident was fine and allowed them to sign the resident out and transport him to the hospital on leave rather than arranging emergency transport. Hospital records later showed the resident had right 6th and 7th rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. The facility’s medical provider (NP-A) reported he was not notified of the fall details until two days later and stated he expected immediate notification when a resident falls with a head injury. Interviews with the Administrator, DON, ADON, weekend supervisor, other nurses, and CNAs consistently described that facility protocol required immediate assessment, documentation, and notification of the physician, responsible party, and nursing leadership after a fall or change in condition, and that this did not occur in this case.
Removal Plan
- Medical Director notified
- Ad hoc QA completed to address notification protocols of family and physician for incident/accidents and change of condition
- DON/designee to educate licensed nurses on proper notification of physician and family for incident/accidents to include any resident change of condition
- DON/designee to educate licensed nurses to notify DON and administrator of all incident/accidents and change of condition that require hospital transfer
- DON/designee performed assessments on all residents with falls in the past 30 days to ensure proper notifications and assessments in place
- MDS/designee updated care plans for all residents with falls in the last 30 days
- All licensed nurses will be educated on incident/accident protocols, to include notification of DON, Administrator, physician and family and resident assessment prior to working their next assigned shift
- DON and/or designee will monitor residents with falls daily to ensure notifications were appropriately made to physician and family
- Administrator to review with the DON weekly to ensure continued compliance
- Results of all audits will be brought to the QAPI committee by DON to review for continued recommendations and compliance
- Protocol will be covered on new-hire orientation by DON/designee
Failure to Assess and Notify After Witnessed Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice, the resident’s care plan, and the resident’s choices following a witnessed fall. An elderly male resident with severe cognitive impairment (BIMS score 00), Alzheimer’s dementia, non‑Alzheimer’s dementia, HTN, DM, CKD stage 2, and a history of wandering and fall risk was observed roaming in and out of other residents’ rooms on the memory unit. On the morning in question, an LVN reported that the resident became angry when redirected from another resident’s room, attempted to swing at the nurse, lost his balance, and fell, striking his face/head and torso against a hallway rail. The LVN observed an abrasion to the resident’s right temple/cheek area and applied a bandage. Despite this witnessed fall with head impact and visible injury, the LVN did not complete an immediate, comprehensive post‑fall assessment as required by facility policy and nursing standards. The electronic health record for that day contained no documentation of vital signs, head‑to‑toe assessment, neurological checks, fall assessment, post‑fall monitoring, pain assessment, or any change in condition related to the fall. The LVN later stated he had performed these assessments but acknowledged he did not document them and did not call for assistance from other clinical staff. He also did not notify the physician, DON, ADON, or weekend supervisor of the fall and injury, although he claimed to have verbally informed an unidentified weekend supervisor who, according to the weekend supervisor interviewed, was never notified. The resident’s family was not informed of the fall or injury at the time it occurred. When the responsible party and another family member visited later that day, they observed a bloody bandage on the resident’s cheek and noted increased confusion and changes in alertness. During a three‑way call with the LVN, the nurse disclosed that the resident had fallen earlier that morning, admitted he had not notified the family because he was unaware he needed to do so, and reassured them that the resident was “fine” and being monitored. Concerned about the resident’s condition, the family requested to take him to the hospital and signed him out on leave. At the hospital, the resident was found to have sustained right 6th and 7th lateral rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. The facility’s records showed that required post‑fall assessments and notifications were not completed at the time of the incident, and key facility staff, including the DON, ADON, weekend supervisor, and NP, confirmed they were not promptly notified of the fall or the resident’s head injury.
Removal Plan
- Notify the Medical Director.
- Complete an ad hoc QA review to address notification protocols for family and physician for incidents/accidents and change of condition, including proper assessments and documentation.
- DON/designee to educate licensed nurses on proper assessments and documentation for incidents/accidents, including any resident change of condition.
- DON/designee to educate licensed nurses to notify the DON and Administrator of all incidents/accidents and change of condition that require hospital transfer.
- DON/designee to assess all residents with falls in the past 30 days to ensure proper notifications and assessments are in place.
- MDS/designee to update care plans for all residents with falls in the last 30 days.
- Educate all licensed nurses on incident/accident protocols, including notification of the DON, Administrator, physician and family, and resident assessment and documentation prior to working their next assigned shift.
- DON/designee to monitor residents with falls daily to ensure notifications, assessments, and documentation are in place.
- Administrator to review with the DON weekly to ensure continued compliance.
- DON to bring results of all audits to the QAPI committee for review and continued recommendations/compliance.
- Include this protocol in new-hire orientation by DON/designee.
Failure to Timely Report Fall-Related Serious Injuries to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged incident of abuse/neglect and serious injury to the appropriate authorities as required by regulation and by its own policies. A cognitively impaired, Spanish‑speaking male resident with Alzheimer’s dementia, non‑Alzheimer’s dementia, anemia, HTN, diabetes, and on antipsychotic and antidepressant medications was admitted with severe cognitive impairment (BIMS score 00) and required supervision or assistance with mobility, transfers, toileting, and ADLs. His care plan identified him as at risk for falls and wandering, with interventions including frequent visual checks, redirection, and assistance with standing and moving. The facility’s written policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation be reported to the Administrator/Abuse Coordinator and, when reportable, to the State Survey Agency and other authorities within 2 hours if involving abuse or serious bodily injury, or within 24 hours otherwise. On the date of the incident, according to a late entry progress note by the DON, the resident was reported to have been roaming in and out of rooms and requiring frequent redirection. At approximately 7:00 a.m., when redirected from a room, he became aggressive and attempted to swing and hit the nurse, lost his balance, and fell against a handrail on his left side. The primary nurse reportedly noted a small abrasion to the left temple area, with no other injuries observed at that time, and documented that the resident was ambulatory and functioning at baseline after the fall, with plans for frequent monitoring post‑fall. The facility’s fall management policy required assessment for injury, investigation of the reason for the fall, completion of an incident/accident report, and notification of the physician and family when a fall occurs. Later that same day, the resident’s family requested hospital evaluation for change of condition with nausea and vomiting, and the resident was sent to the hospital, placed on leave of absence, and medications were put on hold. Hospital records documented that the resident was admitted with a chief complaint that he had fallen, and he was found to have right 6th and 7th lateral rib fractures, a right adrenal hematoma, and a grade 3 liver laceration involving segments 5 and 8. The hospital nurse informed the DON that the resident had fallen at the facility earlier that day, had an abrasion to the cheek, a bruised liver, and rib fractures. The Administrator and DON acknowledged they did not report the incident to the State agency (HHSC) or other required authorities. The DON stated she did not submit a report because, after her assessments and interviews, she ruled out abuse and neglect, and the Administrator stated he did not report because the fall was witnessed and the family transported the resident to the hospital at their discretion. This failure to report an allegation involving a fall with serious bodily injury within the required timeframes constituted the cited deficiency.
Failure to Investigate and Report Serious Injury After Fall
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document an allegation of neglect after a resident sustained serious injuries related to a fall. The resident was an elderly male with severe cognitive impairment (BIMS score 00), Spanish-speaking only, with diagnoses including anemia, hypertension, diabetes mellitus, Alzheimer’s dementia, and non-Alzheimer’s dementia. His care plan identified impaired functional abilities, need for assistance with ADLs, and risk for falls and wandering, with interventions such as assistance with mobility and frequent visual checks. On the date of the incident, a late-entry nursing note documented that the resident had been roaming in and out of rooms, became aggressive when redirected, attempted to swing at the nurse, lost his balance, and fell against a handrail, sustaining a small abrasion to the left temple; he was noted to be ambulatory and at baseline afterward. The resident was later sent to the hospital for a change of condition with nausea and vomiting per family request, and the progress note documented the transfer but did not reference the earlier fall as a cause. Hospital records showed that he was admitted with a chief complaint of a fall and was found to have right 6th and 7th lateral rib fractures, a right adrenal hematoma, and a grade 3 liver laceration involving segments 5 and 8, and he was admitted for trauma-related monitoring and pain control. The facility’s records and interviews revealed that the LVN who witnessed the fall did not report the incident to the Administrator, did not notify the physician, and did not notify the resident’s family member at the time of the fall. Interviews with the Administrator and DON confirmed that, after being notified by the hospital that the resident had sustained serious internal injuries and fractures from a fall that occurred at the facility, they did not initiate a timely, thorough investigation at that time. The Administrator acknowledged he had not investigated the incident when first notified of the hospitalization and injuries. The DON stated she did not investigate when first notified that the resident was in the hospital for a fall, despite knowing of the bruised liver and fractured ribs. The facility had an Abuse, Neglect and Exploitation and Misappropriation of Resident Property Internal Investigation Guidelines policy requiring timely investigation of all allegations of abuse, neglect, and exploitation, but there was no evidence that such an investigation was promptly initiated and documented when the serious injuries and unreported fall were first identified.
Resident with Dementia Left Unattended in Transport Van for Several Hours in Cold Weather
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained free from accident hazards and received adequate supervision, resulting in the resident being left unattended in the facility’s transport van for several hours in cold weather. The resident was an older male with kidney failure requiring dialysis, dementia, and paranoid schizophrenia, with a BIMS score of 6 indicating severe cognitive impairment. He used a wheelchair for mobility, required assistance with ADLs, and resided on a memory care unit. His care plan reflected delirium, impaired mobility, and a need for dialysis three times a week. On the day of the incident, the resident returned from dialysis in the late afternoon, typically between 4:30 PM and 5:00 PM, according to staff and family interviews. The facility’s driver stated he brought the resident back to the unit around that time and informed staff that the resident had returned. However, later that evening, a CNA noted that the resident was not in the common area or in his room when she checked around 8:00–8:30 PM and notified the nurse that she could not locate him. Staff then began searching the unit and other units in the facility. During the search, the CNA went out to her car and noticed movement inside the facility’s transport van parked under the portico. She found the driver’s side door locked, returned to get the nurse, and staff were able to open the passenger side doors. They found the resident seated in the van, buckled into a seat with his seat belt on, wearing a coat and sweater, and his wheelchair stored in the back of the van. Nursing staff present at the scene stated they did not believe the resident, given his dementia and physical condition, was capable of independently exiting the locked unit, wheeling himself outside, folding and loading his wheelchair into the van, and then buckling himself into a seat. The resident told staff that the driver had left him in the van and that he thought the driver was going to come back. Weather records showed outdoor temperatures in the mid-30s Fahrenheit during the time the resident was in the van. The resident’s electronic health record contained no progress notes documenting the incident, the interventions performed, or who was notified. The facility’s policy titled "Safety System for Residents" addressed general resident safety but did not address leaving residents outside. Interviews with the DON and Administrator reflected differing views on how the resident came to be left in the van, with the driver and Administrator asserting the resident had been returned to the unit and somehow made his way back to the van, while nursing staff expressed doubt that the resident could have done so independently. The incident was determined to constitute non-compliance that rose to the level of Immediate Jeopardy for a period of several days, during which the resident remained at risk of harm related to exposure to cold temperatures, discomfort, pain, and anxiety.
Missed Wound Treatments for Pressure Ulcers and Skin Failure
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer and wound care to multiple residents, as documented by missing treatments on wound care administration records and lack of corresponding progress notes. For one resident with severe cognitive impairment and multiple pressure ulcers on admission, including an unstageable left heel wound and several stage 4 pressure wounds on the left foot and toes, the wound care administration records for January and February showed numerous dates on which ordered treatments were not documented as completed. These missed treatments included care for the unstageable left heel wound and stage 4 pressure wounds of the left medial first toe, left fourth toe, and left distal medial foot across multiple days in January and February. Progress notes for this period contained no documentation of wound treatment, and later observation of the resident at a hospital showed wounds on the left heel, right buttocks, and left medial first toe covered with dry dressings. Another resident, an older female with severe cognitive impairment and a diagnosis including open lesions, had a care plan identifying severely impaired skin integrity related to end-stage skin failure of the sacrum, with interventions including cleansing and application of specific dressings such as honey-coated absorbent dressings and later Dakin’s 1/4 strength–soaked gauze. The order summary report detailed daily and as-needed wound care orders for the sacral wound. However, the February wound care administration record showed no entries for multiple dates; instead, those dates were marked as “Missed,” indicating that the ordered wound care was not provided on those days. Progress notes for January and February also lacked documentation of wound treatment. During an observation in early March, the wound care nurse performed sacral wound care, and the old dressing was noted to be dated the previous day, demonstrating that treatments were being done at that time but not on the earlier missed dates. A third resident, an older female with severe cognitive impairment, peripheral vascular disease, and a Kennedy terminal ulcer on the right ischium, had orders for cleansing the site and applying Dakin’s 1/4 strength–soaked gauze with a dry dressing on the day shift and as needed. The wound care administration record for February showed that on two specific dates the wound care entries were marked as “Missed,” indicating the ordered treatments were not provided. The resident’s care plan, revised in early March, noted the need for hospice care due to a terminal cerebrovascular condition and included interventions to administer treatments as ordered and monitor for skin breakdown. Observation with the wound care nurse showed that when wound care was performed, the old dressing on the sacrum was dated the previous day and the nurse followed the ordered cleansing and dressing procedure. In interviews, the wound care nurse stated he had not noticed wound care was being missed because he had not paid attention to the treatment administration records, and explained that he worked Monday through Thursday (later Monday through Friday per the DON), with floor nurses responsible for wound care on other days. The DON stated her expectation that all wounds were treated per physician orders and acknowledged that missing wound care could lead to increased risk of infection or worsening wounds. Overall, across these three residents, the surveyors identified repeated failures to provide and document wound care as ordered, including for pressure ulcers, end-stage skin failure, and a Kennedy terminal ulcer. The wound care administration records showed multiple missed treatments, and there was no supporting documentation in progress notes for the relevant periods. Staff interviews confirmed that the wound care nurse relied on floor nurses to perform treatments when he was not present and that management reviewed treatment records in morning meetings but believed some wound care was missed while staff were learning a new system. The facility’s own wound care policy emphasized that effective prevention and treatment are based on consistently providing routine and individualized interventions, which contrasted with the documented pattern of missed wound care for these residents. These failures placed residents at risk of developing new or worsening pressure ulcers, infection, and pain, as explicitly stated in the report.
Failure to Timely Report Alleged Neglect After Resident Left in Transport Van
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged incident of neglect involving a cognitively impaired resident who was left in a transport van for several hours in cold weather. The resident was an elderly male with kidney failure requiring dialysis, dementia, and paranoid schizophrenia, with a BIMS score of 6 indicating severe cognitive impairment. He used a wheelchair for mobility, required assistance with ADLs, and resided on a memory care unit. His care plan reflected delirium, impaired mobility, and a scheduled dialysis regimen three times a week. Despite this, the facility’s electronic health record contained no progress notes documenting the incident, the interventions taken, or who was notified. On the day of the incident, the resident returned from dialysis in the late afternoon, typically between 4:30 and 5:00 PM. A family member reported being notified later that evening, around 8:30 PM, that the resident was not on the memory care unit, and then around 9:00 PM that he had been found in the transport van. A CNA working that evening stated she noticed the resident was not in the common area or his room around 8:00–8:30 PM and informed the nurse. Staff searched the unit and other units, and the CNA, upon going to her car, observed movement in the transport van. The van’s driver-side door was locked, but staff were able to open the passenger side and found the resident seated with his seat belt fastened; they used another wheelchair because they could not access his wheelchair in the van without the keys. The CNA reported the resident said that the driver had left him in the van and that he thought the driver would return. Interviews with staff revealed conflicting views about how the resident came to be in the van. The driver stated he had returned the resident to the unit around 5:00 PM, informed staff of his return, and did not know how the resident got back to the van. The DON recalled being called at home that the resident could not be found, instructed staff to search the grounds, and was later informed the resident was found in the van; she believed the resident was capable of taking himself back to the van after following a visitor off the secured unit. An LVN, however, stated she did not believe the resident was capable of leaving the locked unit, wheeling himself out, folding and loading his wheelchair, and buckling himself into the van given his dementia and physical condition. The Administrator concluded from his investigation that the driver had returned the resident to the unit and that the resident managed to get back to the van, and he stated he did not report the incident to the state agency because there was no harm to the resident and the driver had brought him back to the unit. This decision was inconsistent with the facility’s written abuse, neglect, and exploitation policy, which required reportable allegations to be reported to the state regulatory agency and other authorities within specified timeframes.
Failure to Use Required Mechanical Lift and Report Pain During Transfer Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of required assistive devices during transfers, resulting in a serious leg fracture for one resident. The resident was an older female with a history of stroke and end-stage renal disease, bedbound with residual left-sided weakness, who used a wheelchair for mobility and required substantial/maximal assistance. Her MDS showed moderately impaired cognition (BIMS 10) but no dementia, no inattention, disorganized thinking, altered consciousness, or behavioral issues, and no reported pain. Her care plan, with an original date of 02/12/26, specified that she was to be lifted mechanically using a Hoyer lift with two or more staff due to impaired mobility, and that she did not attempt to stand from sitting because of medical and safety concerns. On the morning of 12/23/25, the resident was being prepared for transport to her dialysis appointment. According to the resident’s later account to surveyors, her family, and dialysis staff, she was normally transferred via Hoyer lift, but that day several staff, including a chubby female aide and a tall bald male aide, manually transferred her from bed to wheelchair using their hands instead of the mechanical lift. During this transfer, the resident reported that her left leg went between the male aide’s legs and twisted, causing immediate severe pain. She stated she told staff, “I think you broke my leg,” but was nonetheless placed in her wheelchair and transported by van to the dialysis center. The resident consistently stated that the incident occurred at the nursing facility and that she was never transferred out of her wheelchair at the dialysis center because of her pain. At the dialysis center, multiple dialysis staff observed the resident crying and complaining of severe left knee/leg pain. The dialysis RN, dialysis tech, and dialysis nurse manager each reported that the resident said nursing home aides had twisted or hurt her leg during the transfer to the wheelchair, and that she arrived with a Hoyer sling still under her. On assessment, the dialysis RN noted the resident’s pain was 10/10, she could not move her leg, and she cried out when her left knee was touched or when attempts were made to reposition her. EMS was called, and the resident was transported to the hospital, where imaging showed an acute comminuted fracture of the distal left femur, documented as occurring when her leg was twisted during transfer to dialysis, without a fall. Facility nursing staff, including the LVN on duty, ADON, and DON, acknowledged that the resident required a Hoyer lift for transfers, but they did not initially obtain or document a clear account from the resident about the transfer incident, and the DON did not contact the dialysis center to clarify whether an incident had occurred there. Interviews with facility CNAs involved in the transfer revealed inconsistent accounts and confirmed that the resident was not transferred in accordance with her care plan. CNA B, who worked as needed, stated he was called by CNA A to assist with a transfer because the resident was late for dialysis and the Hoyer lift was broken. He reported that he, CNA A, and two other aides transferred the resident from bed to wheelchair using the Hoyer sling under her and a draw sheet, and that the resident complained of leg pain once in the wheelchair. He did not report this pain to the nurse, assuming the primary aides would do so. CNA A denied asking CNA B to help transfer the resident with a Hoyer sling and draw sheet and did not recall the resident reporting pain. CNAs E and F, also as-needed staff, denied recalling a transfer using a Hoyer sling and draw sheet or any specific details from that date. The facility’s own policies required use of mechanical lifts according to manufacturer guidelines and required CNAs to report any change of condition, but the resident’s care plan requirements for mechanical lift use and prompt reporting of pain during transfer were not followed, leading to the identified deficiency.
Removal Plan
- Medical Director notified
- Ad hoc QA completed to address employee transfer techniques using mechanical lifts
- DON/designee to educate all clinical staff on mechanical lift transfers including 2-person assist
- DON/designee to educate all clinical staff to notify nurse of any pain or change of condition during transfers
- DON/designee performed assessment on all residents requiring mechanical lift transfers to ensure safety
- Residents who require mechanical lift transfers will be added to ADL Kardex by DON/designee
- MDS/designee updated care plans for all residents requiring mechanical lift transfers
- All clinical staff will be educated on proper transfer techniques including mechanical lifts prior to working their next assigned shift
- DON/designee will monitor residents requiring mechanical lifts for transfers to ensure compliance
- Administrator to review with the DON the monitoring to ensure continued compliance
- Results of all audits will be brought to QAPI committee by DON to review for continued recommendations and compliance
- This protocol will be covered on new-hire orientation by DON/designee
Failure to Report Alleged Neglect After Improper Transfer Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of neglect related to a serious injury sustained by a resident during a transfer, as required by regulation and by the facility’s own abuse/neglect policy. The resident was an older female with a history of stroke and end-stage renal disease, with moderately impaired cognition (BIMS score of 10) but no diagnosis of dementia or Alzheimer’s disease, and no documented inattention, disorganized thinking, altered level of consciousness, or behavioral issues. Her MDS and care plan documented that she was non-ambulatory, used a wheelchair for mobility, did not attempt to stand due to medical/safety concerns, and required substantial/maximal assistance. The care plan specified that all transfers were to be done with a mechanical Hoyer lift and two or more staff due to impaired mobility. On the day of the incident, the resident was transferred from her bed to her wheelchair at the facility prior to going to dialysis. The resident later consistently reported to multiple individuals that facility aides had manually transferred her instead of using the Hoyer lift, and that her left leg became twisted between a staff member’s legs during the transfer, causing immediate severe pain. She stated she told staff at the time, saying she thought they had broken her leg, but she was nonetheless placed in the wheelchair, transported by van, and sent to dialysis. At the dialysis center, multiple dialysis staff (RN, tech, nurse manager, and case manager) observed the resident crying in severe pain, unable to move her leg, and still sitting in her wheelchair with a Hoyer sling under her. The resident told them that nursing home staff had twisted her leg during the transfer to the wheelchair and that she had reported her pain to facility staff before being sent to dialysis. Dialysis staff did not transfer her to a dialysis chair due to her pain and arranged for EMS transport to the hospital. Hospital records documented an acute comminuted fracture of the distal left femur, with the admission assessment noting that the patient’s leg had twisted during a transfer and that she had not fallen. Facility nursing notes show that the DON and LVN C were informed by hospital staff that the resident had a femur fracture and that the injury was reported as occurring during transfer at the dialysis center. The DON later documented a late entry describing a call from the dialysis RN about the resident’s complaints of leg pain and transfer to the hospital. Interviews with facility staff revealed that the resident was known to require a Hoyer lift for all transfers, that the Hoyer lift was reportedly broken that day, and that multiple CNAs manually transferred the resident using a sling and/or drawsheet. One CNA acknowledged assisting with the transfer and hearing the resident complain of leg pain afterward but did not report this to a nurse, assuming the primary aides would do so. Other CNAs gave conflicting or limited recollections of the transfer. Despite the resident’s repeated statements to dialysis staff and to her family that the injury occurred during a manual transfer at the facility, the Administrator stated the incident was not reportable because it was believed to have occurred at the dialysis center, and the facility did not report the allegation of neglect to the State Survey Agency as required by policy and regulation. The facility’s written policy on Abuse, Neglect, and Exploitation required that all staff ensure alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property are reported to the Administrator (Abuse Coordinator), that the Abuse Coordinator initiate an investigation, and that reportable allegations be reported to the State Regulatory Agency. The report shows that the DON was informed of the resident’s severe leg pain and subsequent hospital transfer, and that the resident’s statements to dialysis staff implicated facility staff in twisting her leg during transfer. However, the DON did not contact the dialysis center to clarify events, relied on staff statements that “nothing happened,” and concluded there was no incident at the facility. The Administrator similarly concluded the event was not reportable because they believed it occurred at the dialysis center. As a result, the allegation of neglect—specifically, failure to follow the resident’s care plan requiring Hoyer lift transfers and the resident’s report that staff twisted her leg during a manual transfer—was not reported to the State Survey Agency within the required timeframe, constituting the cited deficiency.
Failure to Thoroughly Investigate Alleged Neglect After Resident Sustained Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of neglect related to a resident’s left distal femur fracture and to have evidence that all alleged violations of abuse, neglect, exploitation, misappropriation, and mistreatment, including injuries of unknown origin, were fully investigated. The resident was an elderly female with a history of stroke and end-stage renal disease, moderately impaired cognition (BIMS 10), no dementia diagnosis, and no documented behavioral issues. Her MDS and care plan documented that she was non-ambulatory, used a wheelchair, did not attempt to stand due to medical/safety concerns, and required mechanical (Hoyer) lift transfers with assistance from two or more staff. On the date of the incident, she was sent to dialysis by third‑party transport and later diagnosed in the hospital with an acute comminuted closed fracture of the distal left femur, with hospital documentation stating that her leg was twisted during a transfer to the dialysis chair and that there had been no fall. Multiple accounts from the resident and dialysis staff indicated that the resident consistently reported that her leg was twisted and injured during a transfer performed by facility staff from her bed to her wheelchair, and that she normally used a Hoyer lift but was instead manually lifted. The resident told surveyors that several staff, including a chubby female aide and a tall bald male aide, transferred her by hand rather than using the Hoyer lift, and that during the transfer her left leg went between the male aide’s legs and twisted, causing immediate severe pain. She stated she told staff at the facility that she thought they had broken her leg, but she was still placed in her wheelchair and transported to dialysis. At the dialysis center, the resident arrived in severe pain, crying, with a Hoyer sling still under her, and repeatedly told the dialysis RN, dialysis tech, and dialysis nurse manager that nursing home aides had twisted her leg during the transfer to the wheelchair and that she had reported pain to facility staff before being sent to dialysis. Dialysis documentation and staff interviews corroborated that the resident arrived already in severe pain, was never transferred out of her wheelchair into a dialysis chair due to pain, and that she requested to be sent to the hospital. The dialysis RN and dialysis tech both reported that the resident, who was normally calm, pleasant, and cognitively appropriate during treatments, stated that facility staff had twisted her leg during transfer. The dialysis RN reported telling the DON that the resident said the injury occurred at the facility, and the dialysis nurse manager stated that at no time did dialysis staff tell the facility that the incident occurred at the dialysis center. Within the facility, the DON documented that a hospital nurse had said the injury occurred at dialysis and later stated she saw no reason to call the dialysis center to clarify events, did not interview CNA B at the time, and only noted that she had written staff statements “on a notepad somewhere,” with no evidence of a complete investigation. The Administrator stated the incident was not reportable because it happened at the dialysis center. Interviews with facility staff were inconsistent: one LVN did not ask the resident what happened when she returned, the ADON never spoke with the resident about the transfer, CNA B admitted assisting with a manual transfer using a sling and drawsheet because the Hoyer lift was allegedly broken and the resident was late for dialysis, and other CNAs either denied or could not recall the described transfer. Collectively, these actions and omissions demonstrate that the facility did not conduct and document a thorough investigation of the resident’s allegation of neglect and injury as required by its abuse/neglect policy.
Failure to Provide Timely and Adequate Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically timely incontinence care, for two residents who were dependent on staff for these needs. Both residents had severe cognitive impairment, hemiplegia or hemiparesis, and were largely confined to bed, requiring substantial to maximal assistance for toileting and hygiene. Their care plans included interventions such as scheduled toileting, use of briefs, frequent turning and repositioning, application of barrier lotion, and regular skin inspections to prevent skin breakdown and maintain hygiene. On the day of observation, one resident was found in bed with soaked linens and was unable to recall when her brief was last changed. The other resident reported her brief had last been changed the previous night and stated she was wet. During incontinence care, both residents were found to be heavily soaked in urine, with one also having a bowel movement. The CNA providing care did not cleanse the perineal area for either resident, only cleaning the abdominal folds and buttocks. Additionally, the CNA did not change gloves or perform hand hygiene between cleaning different areas after a bowel movement. Interviews with the CNA, LVN, ADON, and DON revealed that staff were expected to perform incontinence rounds every two hours and as needed, but the CNA admitted to not following this schedule due to being busy with other residents. The LVN and nursing leadership confirmed their responsibility to monitor CNA rounds, but could not specify when rounds were last completed. Training records indicated that while staff had received instruction on perineal care, the training did not specifically address the requirement for incontinence care every two hours. The facility's policy required perineal care in accordance with standard practice to prevent skin breakdown and infection.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA D during incontinence care for two residents. CNA D was observed providing incontinence care to two female residents with significant medical histories, including hemiplegia, hypertension, heart failure, renal insufficiency, and severe cognitive impairment. Both residents were dependent on staff for toileting and hygiene, and their care plans included interventions to prevent skin breakdown and maintain skin integrity. During the observed care, CNA D performed hand hygiene before initial resident contact and donned gloves. However, he did not cleanse the peri area for either resident, only cleaning the abdominal folds and buttocks. He failed to change gloves or perform hand hygiene after handling soiled linens and before applying clean briefs and linens, using the same gloves throughout the process. One resident was noted to have a bowel movement, yet the same lapses in infection control were observed. CNA D later acknowledged forgetting to perform hand hygiene and peri care as required. Interviews with the LVN, ADON, and DON confirmed that CNA D did not follow expected infection control practices, including changing gloves and performing hand hygiene during and after care, and completing peri care before applying clean briefs. Facility policy and recent staff training records indicated that proper hand hygiene is required before and after resident contact, and after contact with soiled or contaminated articles. The observed failures were inconsistent with these policies and training.
Failure to Complete Required Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a required discharge summary for a resident who was discharged to another nursing home. The resident, an elderly female with severe cognitive impairment, dementia, hypertension, and malnutrition, was discharged as documented in the MDS assessment and progress notes. While a progress note and a physician discharge summary were present, there was no evidence in the clinical record of a comprehensive discharge summary that included a recapitulation of the resident's stay, diagnoses, course of illness or treatment, pertinent lab, radiology, and consultant results, and a final summary of the resident's status at discharge. Interviews with facility staff revealed that the nurse responsible for the discharge did not complete the discharge summary due to unfamiliarity with a new system and only documented a progress note after being advised by the ADON. The ADON and DON both stated that the nursing team was responsible for ensuring the discharge summary was completed, but neither was aware that it had not been done. The facility's policy required notification of the resident or representative, documentation of the discharge, and provision of written discharge instructions, but these requirements were not fully met in this case.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents involving resident-to-resident altercations. In the first incident, a male resident with severe cognitive impairment and psychiatric diagnoses was physically assaulted by his roommate. The altercation escalated from verbal arguments to physical violence, with the aggressor striking the resident with a ruler multiple times and then stabbing him with a pen, causing scratches and lacerations to the abdomen and neck. The assaulted resident was found on the floor in a disheveled room, exhibiting signs of emotional distress and physical injury, and was subsequently sent to the hospital for evaluation. Staff interviews confirmed that the altercation was not witnessed, but the aftermath indicated significant violence had occurred. In the second incident, a female resident with severe cognitive impairment, a history of hip fracture, and impaired mobility was pushed by another resident while standing near a wheelchair in a common area. This resulted in the resident falling and sustaining a left hip fracture and left wrist fracture, requiring hospitalization and surgery. Staff accounts indicated that the aggressor had a known history of aggressive behavior and required frequent redirection and monitoring. The incident was witnessed by staff, who responded after hearing raised voices and observed the resident in pain with an obvious injury. Both incidents involved residents with known behavioral or cognitive issues, and in each case, the facility did not prevent the altercations that led to physical harm. The facility's failure to ensure adequate supervision, monitoring, and intervention allowed these resident-to-resident altercations to occur, resulting in injury, hospitalization, and emotional distress for the affected residents. The events were substantiated through observation, interviews, and record reviews, confirming that the residents were not protected from abuse as required.
Elopement Due to Inadequate Supervision of High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of wandering, and exit-seeking behaviors was not provided with adequate supervision to prevent elopement. The resident, diagnosed with severe unspecified dementia, schizophrenia, and delusional disorders, had a BIMS score of 00, indicating severe cognitive impairment. The care plan identified the resident as high risk for elopement, with interventions including 15-minute location checks and various diversions. Despite these interventions, the resident was able to break a window and leave the facility undetected. On the day of the incident, the resident was last observed in her room at 7:30 AM. At 7:45 AM, a CNA discovered the resident missing and the window broken when attempting to summon her for breakfast. Staff immediately initiated a search of the unit and grounds, confirmed all other exits were secure, and notified the police when the resident could not be located. The resident was found by police approximately five minutes away from the facility and was exhibiting psychotic behaviors, including hallucinations and delusions, at the time of recovery. Interviews and record reviews confirmed that the resident had previously been on 1:1 supervision, which was later reduced to 15-minute checks due to observed behaviors such as pacing and wandering into other residents' rooms. Staff reported that the required 15-minute checks were being completed, but the resident was able to elope between checks. The incident resulted in the resident being transported to the hospital for evaluation, and the event was classified as Immediate Jeopardy due to the risk of harm and/or serious injury.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL), specifically incontinence care, for two residents who were unable to perform these tasks independently. Both residents had severe cognitive impairment, as indicated by a BIMS score of 00, and were dependent on staff for toileting and personal hygiene. Care plans for both residents required staff to provide incontinence care every two hours and as needed, as well as to avoid doubling briefs to prevent skin breakdown. For one resident, observations revealed that he was found wearing two briefs, both heavily soaked with urine, and had not been changed for several hours. The assigned CNA admitted to not knowing when the resident was last changed and acknowledged awareness of the policy against double briefing. Another CNA from the previous shift also could not recall the last time the resident was changed and confirmed knowledge of the facility's protocols. Staff interviews indicated that training on proper incontinence care and rounding every two hours had been provided, but these practices were not consistently followed. The second resident, who was always incontinent and had a history of diabetes, acute respiratory failure, and stage 4 pressure ulcers, was observed in a room with a strong urine odor and a wet mattress cover. Staff provided incontinence care only after a significant lapse in time, with the assigned CNA stating the last change occurred before breakfast, several hours prior. Both the ADON and DON confirmed that staff were expected to perform rounds every two hours and as needed, and that nurses were responsible for monitoring CNAs. Despite these expectations and documented training, the required care was not delivered as outlined in the residents' care plans.
Failure to Provide Pressure Ulcer Care per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with multiple pressure ulcers did not receive wound care according to physician orders. The resident, an elderly female with severe cognitive impairment and several medical conditions including stage 3 and stage 4 pressure ulcers, was admitted with existing wounds. The care plan outlined specific interventions such as frequent repositioning, skin inspections, and the use of pressure-relieving devices. Physician orders for wound care, including the use of specific dressings and cleansing routines, were provided on admission and detailed in the resident's records. Despite these orders, the facility failed to enter the wound care orders into the electronic treatment administration record (eTAR) system in a timely manner. As a result, wound care was not documented or possibly not provided from the time of admission until several days later, when the orders were finally entered. Interviews with the wound care nurse, nurse practitioner, and DON confirmed that the orders were not in the system and that it was the responsibility of nursing staff to ensure orders were entered and followed. Documentation showed that at least one scheduled wound care treatment was missed, and there was uncertainty about whether care was provided during this period due to lack of documentation. The facility's policies required that physician orders be recorded accurately and that wound care treatments be performed as ordered. The failure to enter and follow the wound care orders as prescribed led to a lapse in the resident's wound care regimen. This deficiency was identified through record review and staff interviews, which revealed gaps in both documentation and the provision of care as ordered.
Failure to Administer Enteral Feedings as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident receiving enteral nutrition via feeding tube was provided with the appropriate treatment and services as ordered by the physician. The resident, a male with severe cognitive impairment, multiple diagnoses including anemia, diabetes mellitus, Alzheimer's disease, and malnutrition, was dependent on a feeding tube and had specific physician orders for the administration of Glucerna 1.5 Cal via PEG tube every four hours. The care plan also included detailed interventions for monitoring and maintaining the resident's nutritional status, including water flushes and head-of-bed elevation. Record review revealed that the resident did not receive the prescribed Glucerna 1.5 feedings on three occasions, as documented in the medication administration record (MAR). Interviews with nursing staff and the DON confirmed that these feedings were missed, and there was no documentation in the clinical record to explain the omissions or indicate that the orders had been placed on hold. Nursing staff were unable to recall or provide reasons for the missed feedings, and the DON verified that the missed administrations were not supported by any progress notes or documentation. The facility's policy required that physician orders be implemented and documented promptly, with any changes or holds to be recorded in the resident's medical record. The lack of adherence to these orders and the absence of documentation for the missed feedings constituted a failure to follow physician directives and provide the necessary care for the resident's enteral nutrition needs.
Failure to Maintain Infection Control Program Due to Lapses in Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to proper hand hygiene protocols during the provision of incontinence and wound care for two residents. Certified Nursing Assistants (CNAs) were observed providing incontinence care without performing hand hygiene before, during, or after the procedure. Specifically, one CNA donned gloves before washing hands, failed to perform hand hygiene after removing gloves, and continued care and handling of supplies without appropriate handwashing. This was confirmed during interviews, where the CNAs acknowledged forgetting to perform hand hygiene and recognized the expectation to do so before and between care tasks, as well as after glove removal. In another instance, two CNAs provided incontinence care to a resident with a stage 4 pressure ulcer and did not perform hand hygiene before donning gloves or after removing them. They also failed to cleanse the peri area as required and handled both soiled and clean items with the same gloves. The wound care nurse, RN, also failed to perform hand hygiene before donning gloves, did not disinfect the area where wound care supplies were placed, and did not change gloves or perform hand hygiene between dirty and clean tasks during wound care. The nurse placed soiled gauze on a clean bedsheet and did not have a designated area for contaminated materials. These actions were confirmed in interviews, where staff admitted to forgetting required hand hygiene steps and not following established protocols. Record reviews indicated that both residents involved had significant medical conditions, including severe cognitive impairment, incontinence, and, in one case, a stage 4 pressure ulcer. Facility policies required hand hygiene before and after resident contact, after contact with soiled items, and during wound care procedures. Despite these policies and reported staff training, the observed failures in hand hygiene and infection control practices were not in compliance with facility protocols. Training records requested by surveyors were not provided.
Failure to Ensure Required Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals as mandated by CMS regulations. Specifically, four residents were not seen by their attending physician at least once every 60 days, and in some cases, not at all within the past 12 months. Instead, all required visits were conducted solely by a nurse practitioner, without alternating with the physician as required. This was confirmed through record reviews, which showed no documentation of physician visits for the residents in question, only visits by the nurse practitioner. The residents affected had complex medical histories, including conditions such as hypertensive chronic kidney disease, paraplegia, dementia, heart failure, and schizophrenia. Their care plans and medication regimens reflected significant needs, including the use of multiple psychotropic and at-risk medications, management of chronic pain, and assistance with activities of daily living. Despite these needs, there was no evidence in the clinical records that the attending physician had conducted face-to-face visits as required, with all documented visits being completed by the physician extender. Interviews with the attending physician revealed an acknowledgment of falling behind on documentation and delegating visits to the nurse practitioner. The physician stated that he would see residents in person if requested by nursing staff but admitted to not keeping up with required face-to-face visits. The facility administrator confirmed there was no specific policy regarding physician visits and that they followed regulatory language. The lack of physician visits was further corroborated by the absence of documentation in the residents' clinical charts.
Failure to Administer and Document Medications for Resident with Dementia
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with multiple complex diagnoses, including dementia, chronic kidney disease, and Alzheimer's disease. On two consecutive mornings, the resident was not administered her prescribed morning medications, which included critical drugs for blood pressure, cholesterol, depression, and other conditions. The medication administration record (MAR) indicated that the medications were marked as refused, but there was no documentation of further attempts to administer the medications or of appropriate follow-up actions. Interviews with staff revealed that the medication aide attempted to administer the medications but, after the resident refused and spit out the medications, did not make additional attempts or notify the charge nurse as required. The charge nurse, when notified, did not document the refusals or attempt to encourage the resident to take the medications, citing being too busy as the reason for inaction. There was also no documentation in the nursing progress notes regarding the refusals, the reasons for non-administration, or any notification to the physician as required by facility policy. The facility's policy required that if a resident refused two consecutive doses of a vital medication, the physician should be notified, and all refusals should be documented. However, these procedures were not followed. The lack of proper documentation, follow-up, and physician notification resulted in the resident missing multiple doses of essential medications over two days, with no evidence of appropriate interventions or communication among staff.
Unnecessary Prescription of Austedo Without Adequate Indication
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, specifically regarding the prescription of Austedo to two residents without adequate indications for its use. For one resident, who had diagnoses including hypertensive chronic kidney disease, osteoarthritis, morbid obesity, and dementia, there was no documented diagnosis of tardive dyskinesia or evidence of involuntary movements prior to the prescription of Austedo. Multiple AIMS assessments showed no signs of tardive dyskinesia, and nursing notes did not document any movement disorders. The decision to prescribe Austedo was influenced by a pharmaceutical representative's presentation and a subsequent observation of minor pill rolling, but there was no substantial clinical evidence supporting the need for the medication. For the second resident, who had paraplegia, chronic pain, and a history of depression and anxiety, there was also no documented evidence of tardive dyskinesia or abnormal involuntary movements in AIMS assessments or nursing notes prior to the prescription of Austedo. The resident herself reported that her head movements were voluntary and used as a coping mechanism for anxiety, not as a result of uncontrolled movements. Staff interviews confirmed a lack of awareness of any movement issues or the purpose of the Austedo prescription. The facility’s policy required a formal diagnosis of tardive dyskinesia by a physician or extender before initiating treatment, and interdisciplinary team involvement in treatment decisions. However, in both cases, Austedo was prescribed based on limited or subjective clinical observations rather than documented evidence or formal diagnosis, and without clear interdisciplinary team involvement. This resulted in the administration of a potentially unnecessary medication to both residents.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident's call light was observed on the floor and out of reach, despite the resident's care plan specifying that the call light should be within reach due to a high fall risk. The resident, an elderly female with Alzheimer's disease and esophagitis, required substantial to maximum assistance with transfers and sit-to-stand activities, as documented in her medical records. During the observation, the resident was only able to answer yes or no questions, indicating limited communication abilities. Staff interviews revealed that the call light should have been within reach at all times, and that staff are expected to check the call light's placement each time they enter a resident's room. The last staff member to enter the room believed the call light was within reach but was unsure of the risks if it was not. The Director of Nursing confirmed that staff are responsible for ensuring call lights are accessible, acknowledging that failure to do so could prevent residents from reaching staff when needed. The facility's Resident Rights policy did not address the right to reasonable accommodations.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was fully implemented for a resident identified as a fall risk. The resident, an elderly female with Alzheimer's disease and esophagitis, required substantial to maximum assistance with transfers and sit-to-stand activities. Her care plan included specific fall prevention interventions such as keeping the call light within reach, using a half bed rail, ensuring the bed was in the lowest position, and placing a fall mat on the floor. However, during observations, the bed was not in the lowest position, the fall mat was not in place, and the bed rails were not raised as required by the care plan. Interviews with facility staff revealed a lack of awareness and adherence to the resident's care plan interventions. An LVN acknowledged that the fall mat and bed rail should have been in place but was unsure why they were not. A CNA admitted to forgetting to lower the bed and place the fall mat after providing care and was unaware of the risks associated with not following these interventions. The DON confirmed that all staff were responsible for ensuring fall interventions were in place each time they entered the room, as outlined in the facility's care plan policy.
Failure to Provide Feeding Assistance to Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and esophagitis, who was on a puree diet with thickened liquids and required total assistance with eating, was not provided with the necessary feeding assistance. The resident's care plan did not address the need for feeding assistance, despite documentation in the MDS and physician's nutrition notes indicating the requirement for partial to full assistance and a risk for malnutrition. On the day in question, the resident's breakfast remained untouched on the bedside table, and the resident confirmed she had not been assisted with feeding, although she expressed a desire to eat. Staff interviews revealed that the CNA responsible for the resident attempted to feed her but was unsuccessful and failed to report to the LVN that the resident had not eaten. The LVN was unaware of the missed meal until later and then provided feeding assistance. The facility's policy required staff to report to a licensed nurse if food consumption was 25% or less, but this was not followed. The Assistant Executive Director and DON confirmed that CNAs are responsible for assisting with feeding and notifying nursing staff if a resident does not eat, and acknowledged the risk of unwanted weight loss if meals are not consumed.
Resident-to-Resident Altercation Leads to Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in a serious injury. On the specified date, a resident with severe cognitive impairment and a history of being a fall risk was involved in an altercation with another resident. The altercation occurred when the second resident, also with severe cognitive impairment and a history of anxiety and neurological conditions, pushed the first resident as she attempted to stand from a couch. This push caused the first resident to fall and sustain a right hip fracture, necessitating hospitalization and surgery. The incident was witnessed by staff members who reported that the second resident was verbally aggressive and had a history of paranoia, believing that others were stealing her belongings. Despite this behavior, her care plan did not reflect any interventions for such behaviors. On the day of the incident, the second resident was reportedly agitated and accused the first resident of entering her room, which led to the physical altercation. Staff members intervened immediately, but the first resident had already sustained a significant injury. Interviews with staff revealed that the second resident had been verbally aggressive in the past but had not previously exhibited physical aggression. The facility's failure to adequately monitor and address the second resident's behaviors, as well as the lack of appropriate interventions in her care plan, contributed to the incident. The deficiency was identified as an Immediate Jeopardy situation, indicating a serious threat to the health and safety of the residents involved.
Misappropriation of Resident's Medication by ADON
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property when the Assistant Director of Nursing (ADON) took two morphine pills prescribed for the resident. The resident, who was moderately cognitively impaired and had a history of lung and brain cancer, was admitted with a bottle of morphine pills and liquid morphine. On the morning of the incident, the ADON informed a Licensed Vocational Nurse (LVN) that there was a change in the resident's medication orders, stating that the morphine pills were discontinued, and took the pills and the count sheet to her office. Later that day, it was discovered that the resident's Medication Administration Record (MAR) indicated he was due for a morphine pill, but there were none available on the cart. The ADON returned the pills with a new count sheet showing fewer pills than expected. Upon investigation, it was found that the original count sheet had been altered to show fewer pills than the resident had initially. The ADON was suspended pending further investigation. The facility's policy on abuse, neglect, and misappropriation of resident property was not adhered to, leading to this deficiency.
Failure to Administer Cancer Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of the cancer medication Ibrance. The resident, a female with a history of breast cancer, heart failure, and mild cognitive impairment, was prescribed Ibrance to be taken daily for 21 days, followed by a week off. However, the resident missed four doses of the medication over a four-day period. This lapse occurred between August 26 and August 29, 2024, as documented in the Medication Administration Records (MARs). The Director of Nursing (DON) acknowledged issues with the delivery of Ibrance from a specialty pharmacy, which was not the facility's usual pharmacy. Despite these logistical challenges, the DON confirmed that there was no valid reason for the missed doses, emphasizing the importance of maintaining therapeutic blood levels for cancer medications. The facility's Medication Administration policy mandates that medications be administered as prescribed, and nurses are required to return to residents who are unavailable during medication passes to ensure they receive their doses.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary personal hygiene services to three residents, leading to deficiencies in their care. Resident #23, an elderly female with severe cognitive impairment, was observed with long facial hairs on multiple occasions, despite expressing a desire for their removal. The facility's records showed no documentation of shaving refusals, and interviews with staff revealed that showers and personal hygiene tasks, including facial hair removal, were not consistently performed due to staffing issues. Resident #55, a legally blind female requiring assistance with all activities of daily living, was also observed with unwanted facial hair. She expressed embarrassment over her facial hair, yet there was no record of her being shaved. Interviews with staff indicated a reliance on CNAs to perform these tasks, but there was a lack of follow-up to ensure completion. The facility's policy stated that hair care and shaving should be provided according to standard practice guidelines, which were not adhered to in this case. Resident #81, a female with a history of cardiovascular disease and cognitive impairments, did not receive consistent showers or baths as required. Documentation showed numerous instances where bathing did not occur, and interviews with staff highlighted issues with staffing and scheduling that prevented showers from being completed. The facility's policy required documentation of bathing procedures, which was not consistently done, leading to a deficiency in the resident's hygiene care.
Food Safety and Hygiene Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in both the North and South kitchens, as observed during a survey. In the North kitchen, several food items, including cooked chicken and rice soup, cheese, sautéed mushrooms, cooked meatloaf, and a bag of uncooked biscuits, were found without labels or dates indicating when they were opened or prepared. Additionally, ground meat was thawing in the fridge without a date indicating when it was removed from the freezer. This lack of labeling and dating was acknowledged by staff members, who confirmed that it was their responsibility to ensure all food items were properly labeled and dated to prevent foodborne illnesses. In the South kitchen, Nutrition Aides M and L were observed not wearing beard guards while handling food and clean dishes, despite having facial hair. Nutrition Aide M was preparing drinks for the lunch meal, and Nutrition Aide L was putting away clean dishes. Both aides admitted to forgetting to wear beard guards, and it was revealed that there were no beard guards available for them to use at the time. The Dietary Manager (DM) confirmed that it was his responsibility to ensure beard guards were available and that staff were trained to wear them to prevent hair contamination in food. The facility's policies on the use of leftovers and employee infection control were not followed, as evidenced by the lack of proper labeling and the absence of beard guards. The Federal Food Code requires that ready-to-eat, time/temperature-controlled foods be clearly marked with a date for consumption or disposal, and that hair restraints be used effectively. The failure to comply with these standards could place residents at risk for foodborne illnesses and contamination.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident's right to dignity and respect was upheld by not providing a privacy cover for the resident's catheter urine collection bag. This deficiency was observed in the case of a male resident with multiple medical conditions, including an indwelling catheter. The resident's catheter bag was repeatedly observed without a privacy cover, lying on the floor beside the bed, which the resident expressed made him feel uncomfortable, especially during visits. Interviews with facility staff, including an LVN, ADON, and DON, revealed a lack of awareness and communication regarding the absence of a privacy cover for the resident's catheter bag. The staff acknowledged the importance of maintaining privacy and dignity by covering catheter bags and ensuring they are not placed on the floor. The facility's policy on catheter care emphasized the need for privacy and proper positioning of catheter bags, which was not adhered to in this instance.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had access to her call light, which is necessary for requesting assistance. The resident, a legally blind female with muscle wasting and difficulty swallowing, required substantial assistance with all activities of daily living (ADLs) as noted in her care plan. During observations, the resident was found sitting in her wheelchair with the call light cord on the floor behind her and under the bed, making it inaccessible. The resident reported that she would either yell for help or wait for someone to check on her, as she was unaware of the call light's location. An interview with an LVN revealed that the nursing staff was unaware of why the call light was not placed within the resident's reach when she was positioned in her wheelchair. The facility's policy on call lights, dated earlier in the year, stated that staff should ensure call lights are within reach when leaving a resident's room. This oversight in following the policy could potentially place residents at risk of not being able to call for assistance when needed.
Failure to Maintain Proper Wound Care for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a diabetic wound on a resident's left upper side second toe was properly covered with a dressing, as per the physician's orders and the resident's care plan. The resident, who had a severely impaired cognition and was at risk of diabetic foot ulcers, was observed with an uncovered and bleeding wound. The last recorded wound care was administered two days prior to the observation, and the resident could not recall when the wound was last dressed. A dressing dated a week earlier was found inside the resident's sock, indicating a lapse in wound care. Interviews with the nursing staff revealed a lack of awareness and communication regarding the resident's wound care needs. The LVN responsible for wound care was not informed that the dressing had come off, and the RN admitted to using an old dressing without updating the date and initials. Both nurses acknowledged the potential risk of infection and wound deterioration due to the failure to follow physician orders. The Director of Nursing confirmed that the staff was expected to follow orders and apply new dressings as needed, but there was a lack of consistent training and documentation practices among the nursing staff.
Improper Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a risk of urinary tract infections. The resident, a male with multiple health conditions including renal insufficiency and diabetes, was observed multiple times with his catheter urine collection bag improperly placed on the floor or tangled with nephrostomy tubes. This improper placement was noted to cause discomfort and pressure for the resident, as well as a risk of urine backflow. Interviews with nursing staff, including LVNs and the ADON, revealed a lack of awareness and adherence to proper catheter care protocols. Staff acknowledged that the catheter bag should be hung at the lowest part of the bed to prevent infection and ensure proper drainage. However, observations showed that the bag was frequently left on the floor, and staff were not consistently ensuring it was correctly positioned. The facility's policy on the care and removal of indwelling catheters emphasized the importance of following standard practice guidelines, yet these were not adhered to in the case of the resident. The DON was not informed of the repeated issues with the catheter bag placement, indicating a communication breakdown within the facility. This oversight placed the resident at risk of health decline and potential infection.
Failure to Maintain Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by a significant weight loss of 15.51% over a period of 30 days. The resident, an elderly female with a history of stroke, Alzheimer's Disease, and Depression, was observed to have a decline in appetite and was pocketing food during meals. Despite being on a therapeutic diet and receiving nutritional supplements, the resident's weight loss was not addressed in a timely manner. Interviews with staff revealed a lack of communication and awareness regarding the resident's nutritional status. The resident's physician was not informed of the decrease in appetite or the behavior of pocketing food, which could have prompted timely interventions. Additionally, the dietitian and nursing staff were not aware of the significant weight loss due to discrepancies in the recorded weights, which were not followed up on promptly. The facility's policy on weight monitoring was not adhered to, as significant weight changes were not re-evaluated or communicated to the necessary parties, including the physician and dietitian. The Director of Nursing acknowledged the weight discrepancy and the failure to address the resident's weight loss, which was compounded by the resident's transfer between secured units and the lack of consistent monitoring and intervention.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as required by State and Federal laws. This deficiency was observed in the case of two residents and one medication cart. The medication cart for the 100 Hall was found unsecured, with the locking mechanism not engaged, while the responsible RN was away from the cart. The RN admitted to having the only key and acknowledged the risk of residents accessing medications not meant for them. Resident #177 was found with a new box of arthritis pain cream stored at his bedside table, which was not secured in a lock box or the medication cart. The resident, who had a history of severe pain and multiple medical conditions, was unable to communicate where he received the medication. The facility did not have a physician's order for this over-the-counter medication, and the charge nurse confirmed that residents were not allowed to self-administer medications or have them in their rooms. Similarly, Resident #189, who had a moderately impaired cognition and multiple medical diagnoses, was found with a tube of arthritis pain cream, zinc oxide cream, and eye drops in his nightstand. The resident admitted to self-administering the cream due to delays in nursing staff response. The charge nurse confirmed that residents were not permitted to have medications in their rooms, as it posed a risk of adverse reactions and staff being unaware of the medications being taken. The facility's policy stated that medications should be accessible only to authorized personnel, highlighting the failure to adhere to this policy.
Failure to Adhere to Resident's Dietary Needs
Penalty
Summary
The facility failed to ensure that food was prepared and served according to a resident's specific dietary needs, as evidenced during a lunch meal observation. Resident #29, who had severe cognitive impairment and a history of conditions affecting swallowing, was ordered a pureed diet with nectar thickened liquids. However, during the lunch meal, the resident was served whole potato chips and a whole piece of cake, both of which were inconsistent with his dietary requirements. Additionally, the resident was given thin liquids instead of the prescribed nectar thickened liquids. The deficiency was observed when a staff member mistakenly provided whole potato chips to Resident #29, believing he had a sub sandwich, which was not the case. The resident was also observed with a whole piece of cake and thin tea, both of which were not in line with his dietary orders. The surveyor intervened to prevent the resident from consuming these inappropriate items, and the dietary staff subsequently provided the correct pureed and thickened items. Interviews with the dietary manager, dietitian, and assistant administrator revealed a lack of clarity on why the resident was served inappropriate food items. The dietary manager acknowledged that staff should have recognized the resident's dietary needs and provided the correct items. The facility's policy emphasized the importance of adhering to residents' dietary requirements to prevent risks such as aspiration and choking, which were not followed in this instance.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically for one resident who was reviewed for call light access. The resident, a male with hypertension, hemiplegia, and hemiparesis, was found without a call light cord in his room, which is necessary for him to call for assistance. Despite the resident's care plan indicating the need for a call light within reach due to his fall risk, the call light was missing, and the resident was unable to communicate effectively due to cognitive impairments. Interviews with staff, including a CNA, LVN, ADON, and the Maintenance Director, revealed a lack of awareness regarding the missing call light cord for the resident. The staff acknowledged the importance of having a call light within reach and the potential risks of not having one, yet there was no documentation in the maintenance logbook about the missing call light. The facility's policy on call lights did not address the requirement for rooms to be equipped with a functioning call light, contributing to the oversight.
Failure to Maintain Resident's Bed in a Timely Manner
Penalty
Summary
The facility failed to ensure a resident's right to a safe, clean, comfortable, and home-like environment. This deficiency was observed when a resident's bed was not made in a timely manner after being sanitized, preventing the resident from lying down. The resident, who was severely cognitively impaired and required partial assistance for activities of daily living, was observed with an unmade bed that had small puddles of liquid on the mattress. The liquid appeared to have been sprayed some time ago, leaving wet areas and dried rings on the mattress. A Certified Nursing Assistant (CNA) was responsible for the resident's care and stated that the bed was stripped for cleaning on the resident's shower day. The CNA had asked housekeeping to spray the mattress but did not return to wipe it down, assuming it was not an issue since the resident usually stayed in her wheelchair until after dinner. However, the resident expressed a desire to lie down after lunch, which was not possible due to the unmade bed. The CNA was unaware of the resident's request to get into bed and did not perceive any risk to the resident. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that it was expected for CNAs to clean and make beds on shower days. The LVN acknowledged that leaving the bed uncleaned for an extended period was unacceptable and posed a risk of infection. The DON confirmed that CNAs were responsible for ensuring bed linens were replaced daily and should report any issues to their nurses. The facility was experiencing a linen shortage, which may have contributed to the issue, but the failure to make the bed in a timely manner was not acceptable.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with Medication Cart #1. On the specified date, the cart was found unlocked and unattended near one of the main entrances of the facility. This occurred while two staff members were initially present at the nurses' station but left the area shortly after. During this time, four residents in wheelchairs were in the immediate vicinity, and another resident wheeled himself into the building from outside. LVN A, who was in an office without windows, confirmed that the cart belonged to MA B, who was down the hall at the time. Upon being interviewed, MA B could not provide a reason for leaving the cart unlocked and unattended. She mentioned that she last used the cart before 10:00 AM and typically took it with her down the halls when administering medications. The facility's Director of Nursing (DON) and the Administrator both acknowledged that staff had been trained to keep medication carts locked when unattended, emphasizing the risk of residents accessing medications. The facility's policy clearly stated that medication carts should be kept closed and locked when out of sight of the medication nurse.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, resulting in an incident where Resident #11 was physically harmed by Resident #12. Resident #12, who had a diagnosis of dementia with behavioral disturbances, was known to exhibit aggressive behaviors, including hitting other residents. Despite this, the facility did not maintain adequate supervision or interventions to prevent further incidents. On the day of the incident, Resident #11 was found on the floor with bloody nostrils, while Resident #12 stood over her, yelling aggressively. Resident #11 was subsequently diagnosed with a maxillary fracture and epistaxis due to the assault. Resident #12 had a history of increased aggression and auditory hallucinations, which led to multiple altercations with other residents. The facility's records indicated that Resident #12 had been involved in several incidents of physical aggression from 03/27/24 to 04/02/24. Despite these documented behaviors, the facility's interventions, such as frequent visual checks and attempts to medicate Resident #12, were insufficient. The family of Resident #12 refused medication adjustments, and the facility did not consistently implement 15-minute monitoring checks, which were only in place for a brief period. Interviews with staff revealed a lack of clear communication and specific instructions on how to manage Resident #12's aggressive behaviors. Staff members were aware of Resident #12's increased aggression but were not consistently informed about the necessary precautions or interventions. The facility's failure to maintain continuous monitoring and adequately address Resident #12's behaviors directly led to the incident where Resident #11 was injured. This deficiency highlights the facility's inability to protect residents from abuse and ensure their safety.
Removal Plan
- The facility implemented visual checks for Resident #12.
- The facility initiated a behavior log to monitor Resident #12's aggression.
- The facility contacted the psychiatric nurse practitioner for medication adjustments.
- The facility attempted to educate Resident #12's family on the necessity of medication adjustments.
- The facility placed Resident #12 on checks.
- The facility sent Resident #12 to the hospital for a psychiatric evaluation.
- The facility conducted in-service training for all staff on abuse, neglect, exploitation, misappropriation of resident property, and resident-to-resident behaviors.
- The facility conducted in-service training for all staff on fall prevention and fall management.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for six residents. Specifically, the facility did not ensure that soiled briefs were properly disposed of, privacy curtains were clean, and ceiling vents were free of dust and debris. These deficiencies were observed in the rooms of Residents #2, #3, #4, #5, #6, and #7, potentially placing them at risk for contamination and an unsafe environment. Resident #2, a [AGE] year-old female with moderate cognitive impairment, was found with a soiled brief containing fecal matter in her trash can and dried brown stains on her privacy curtain. The resident stated that the brief was changed during wound care by a nurse but was not aware it was put in the trash can. Similarly, Resident #3, a [AGE] year-old female with cognitive intact, had a soiled brief in her trash can, which she placed there herself due to CNAs not emptying the bathroom trash can. Residents #4, #5, and #6, all with severe cognitive impairment, had stained privacy curtains and dusty ceiling vents with black marks around the vent openings. Resident #7, with moderate cognitive impairment, also had a dusty ceiling vent with black marks. Interviews with staff, including CNAs, LVNs, housekeepers, and maintenance personnel, revealed a lack of adherence to proper procedures for disposing of soiled briefs and maintaining cleanliness of privacy curtains and ceiling vents. Staff acknowledged the deficiencies and the potential risks of contamination and an unsafe environment for the residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide necessary incontinence care to six residents, leading to issues with personal hygiene and dignity. Resident #2, a female with moderate cognitive impairment, was found with a wet brief that had not been changed since the previous night. She had a dressing on her coccyx, indicating a potential risk for skin issues. Resident #10, a male with severe cognitive impairment, was found wearing two heavily soaked briefs, which he requested due to the long wait times for changes at night. His skin was intact, but the practice of double briefing was against facility policy. Resident #1, a male with severe cognitive impairment and hemiplegia, was found in a room with a strong urine odor. His brief had not been changed since the previous night, and he was wearing two heavily soaked briefs. His Power of Attorney confirmed that this was a recurring issue. Resident #8, a female with severe cognitive impairment and multiple health issues, was also found with a heavily soaked brief that had not been changed since the previous night. She had been complaining about the lack of timely changes, and her skin was intact. Resident #9, a female with severe cognitive impairment and acute kidney failure, was found with two heavily soaked briefs containing fecal matter. She could not recall when she was last changed. Resident #13, a female with severe cognitive impairment and chronic kidney disease, was found with a heavily soaked brief that had not been changed overnight. Interviews with staff revealed a lack of awareness and adherence to the facility's policy of checking and changing residents every two hours. The DON confirmed that staff had been trained on this policy, but the issue persisted, particularly with the night shift staff not performing their duties adequately.
Failure to Provide Wound Care as Per Physician Orders
Penalty
Summary
The facility failed to ensure that two residents with pressure ulcers received necessary treatment and services according to physician orders. Resident #5, a [AGE] year-old female with severe cognitive impairment and chronic kidney disease, did not receive wound care on two consecutive days as per the physician's orders. The wound care nurse was off duty, and the floor nurses were responsible for wound care but failed to perform it. The dressing on Resident #5's wound was dated two days prior, indicating a lapse in care. The LVN responsible for the wound care admitted to not being aware of the missed care and acknowledged the potential for the wound to worsen due to this oversight. Resident #2, a [AGE] year-old female with moderate cognitive impairment and cerebral ischemic, also did not receive wound care as per physician orders. The wound care was supposed to be performed daily, but the LVN responsible for the care admitted to not performing it on two consecutive days due to a high workload. The LVN also admitted to signing the treatment administration record without actually performing the wound care. The DON was unaware of these lapses and stated that the nursing staff knew they had to follow physician orders. The DON also mentioned that the facility had a wound care nurse, but she was out, and the floor nurses were responsible for wound care in her absence. The facility's policy on wound care, dated July 2018, was not followed, leading to the deficiencies. The policy required reviewing orders, gathering supplies, and following standard precautions and infection control methods. The failure to adhere to these guidelines resulted in missed wound care for both residents, potentially worsening their conditions. The DON acknowledged the responsibility for ensuring wound care was provided and monitored but was not aware of the lapses in care until the survey.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that two residents received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #1, a [AGE] year-old female with severe cognitive impairment and multiple diagnoses including hemiplegia and muscle weakness, did not receive showers as scheduled for December 2023, January 2024, and February 2024. Despite her care plan indicating the need for substantial assistance with bathing, there were multiple instances where showers were either not documented or not provided. Interviews with staff revealed inconsistencies in documentation and follow-up on shower refusals, leading to gaps in care for Resident #1. Resident #2, a [AGE] year-old female with no cognitive impairment but requiring partial assistance with bathing, also did not receive showers as scheduled. Her care plan indicated a preference for morning baths and assistance with self-care, but her ADL Flow Records showed several missed showers. Interviews with Resident #2 and staff highlighted issues with staff availability and documentation, resulting in missed showers and inconsistent care. Both residents expressed dissatisfaction with the lack of consistent bathing, and staff interviews confirmed that missed showers could lead to potential health risks such as skin breakdowns and infections. The facility's policy on bathing required staff to document all provided or refused showers in the electronic health record (EHR). However, interviews with CNAs and LVNs revealed that this documentation was not consistently completed, and there was a lack of follow-up on missed showers. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the responsibility of ensuring showers were provided and documented, but the report indicated that these procedures were not effectively implemented, leading to the identified deficiencies.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. Specifically, the facility did not ensure that the oxygen concentrator and nasal cannula for a resident were dated, labeled, and changed on a weekly basis. Additionally, the facility did not deliver oxygen as ordered by the physician at 2 liters per minute, instead delivering it at 2.5 liters per minute. This failure placed the resident at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection. The resident involved was a [AGE] year-old female with multiple diagnoses, including hypoxemia, chronic pain, elevated blood pressure, anemia, shortness of breath, dehydration, and hypokalemia. The resident's baseline care plan indicated issues with breathing patterns and included interventions such as adjusting the head of the bed, administering medications and respiratory treatments, and monitoring respiratory rate and effort. Despite these orders, observations revealed that the resident's nasal cannula and water bottle were not labeled or dated, and the water bottle was empty. The oxygen machine was delivering 2.5 liters per minute instead of the prescribed 2 liters. Interviews with staff members, including an LVN, CNA, ADON, and DON, revealed inconsistencies in the monitoring and maintenance of the resident's oxygen equipment. The LVN admitted to not being sure of the risks associated with not changing the tubing weekly, while the CNA did not notice the empty water bottle. The ADON and DON both acknowledged that the nursing staff was responsible for following physician orders and ensuring the equipment was properly maintained, but this was not consistently done. The facility's policy on applying an oxygen delivery device was not adhered to, leading to the identified deficiencies.
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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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