Windsor Nursing And Rehabilitation Center Of Wesla
Inspection history, citations, penalties and survey trends for this long-term care facility in Weslaco, Texas.
- Location
- 721 Airport Dr, Weslaco, Texas 78596
- CMS Provider Number
- 675363
- Inspections on file
- 25
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Windsor Nursing And Rehabilitation Center Of Wesla during CMS and state inspections, most recent first.
A resident admitted with severe cognitive impairment, multiple neurologic and metabolic diagnoses, and a gastrostomy feeding tube had enteral feeding orders and a baseline care plan documenting dependence on tube feeding, but no physician order was obtained for Enhanced Barrier Precautions (EBP) from admission through the initial days of stay. Interviews with the DON, ADON, and Administrator confirmed that a feeding tube is considered an indwelling or invasive device under facility policy and that such residents require an EBP order, and record review verified that no such order was present despite staff reportedly following EBP practices.
Surveyors found that a baseline care plan for a newly admitted, tube-fed resident with severe cognitive impairment and multiple neurologic and nutritional diagnoses failed to include enhanced barrier precautions (EBP), despite the presence of an indwelling feeding tube and active enteral feeding orders. The baseline care plan noted dependence on tube feeding and water flushes but indicated no special precautions were required, and leadership (DON, ADON, ADM) later acknowledged that EBP should have been documented for residents with feeding tubes. This omission did not align with the facility’s policy requiring baseline care plans within 48 hours of admission to include essential healthcare information needed for proper care.
A resident readmitted with rhino virus/possible flu and pneumonia was ordered droplet precautions, but the facility did not promptly post droplet/isolation signage or set up PPE at the room entrance. Some CNAs and nurses learned of the precautions only by verbal report, and at least one CNA provided early-morning incontinence care using only gown and gloves based on prior EBP status, unaware that mask and face shield were also required. Staff interviews showed confusion over who was responsible for initiating and posting precautions, and leadership confirmed that signs and PPE should have been in place upon admission per the infection prevention and control policy requiring transmission-based precautions consistent with CDC guidelines.
A resident with severe cognitive impairment and behavioral disturbances was placed on physician-ordered 1:1 observation every hour, but staff failed to document this monitoring for a six-hour period on the MAR. Although the assigned nurse stated the observation was performed, she did not sign the record as required by facility policy, and the DON confirmed the omission. The nurse had received recent documentation training, but the required entries were not made.
The facility's activities program was directed by an unqualified Activity Director who lacked required certification, experience, and enrollment in an approved program, as confirmed by record review and staff interviews. This deficiency affected all residents due to the absence of a qualified professional overseeing activities.
A resident with diabetes and peripheral arterial disease was admitted and began receiving insulin and anticoagulant medications per physician orders, but the baseline care plan developed within 48 hours did not include these essential medications. Staff interviews and record reviews confirmed the omission, which was contrary to facility policy and professional standards.
A resident with paraplegia and severe cognitive impairment, who was care planned for total dependence and required two-person assistance for bathing, was observed receiving a bed bath from only one CNA. Staff interviews revealed inconsistent understanding of when two-person assistance was needed, and facility leadership acknowledged the absence of a clear policy on supervision and CNA responsibilities for assist levels.
The facility did not provide RN coverage for the required 8 consecutive hours on one day, with only 3.91 hours of RN presence documented. The DON and Administrator acknowledged responsibility for ensuring RN coverage and stated that if the scheduled RN was unavailable, it was their duty to find coverage or cover the shift themselves. Facility policy requires 8 consecutive hours of RN coverage daily, including the DON's hours, but the lapse was not documented due to salaried staff not clocking in.
A resident with severe cognitive impairment and a history of schizoaffective disorder was administered risperidone without consistent documentation of an adequate medical indication in the official records. Although some notes referenced the diagnosis, it was not uniformly present in the medical record until the day of the survey, resulting in a failure to ensure the drug regimen was free from unnecessary drugs.
A resident with a history of schizoaffective disorder had inconsistent documentation in her clinical records, with some entries incorrectly listing schizophrenia as her diagnosis. This discrepancy appeared in the care plan, physician orders, and some NP notes, despite the primary care provider's diagnosis of schizoaffective disorder. The error resulted in incomplete and inaccurate medical records, not in accordance with professional standards.
A resident with a history of amputation and chronic pain missed multiple doses of prescribed Acetaminophen-Codeine when nursing staff failed to ensure the medication was available and instead administered Tylenol 500 mg without a proper order. The resident questioned the nurse about the medication, but was incorrectly assured it was the prescribed drug. The nurse did not notify supervisors or use the emergency medication supply, and the issue was only discovered after the resident filed a grievance.
A resident with a history of amputation and chronic pain did not receive the ordered Acetaminophen-Codeine for pain management, instead receiving Tylenol 500 mg without proper documentation or notification to supervisors. The LPN failed to update the MAR and did not inform staff about the medication shortage, resulting in incomplete and inaccurate medical records.
The facility failed to obtain signed and dated consents for psychotropic medications for three residents, leading to the administration of these medications without proper informed consent. The residents had various cognitive impairments and diagnoses, and the consents were either missing, signed by the wrong party, or undated.
The facility failed to maintain clinical records in accordance with accepted professional standards for three residents, as consent forms for antipsychotic and antidepressant medications were either missing, incomplete, or improperly signed by the residents instead of their responsible parties. The residents involved had significant cognitive impairments and complex medical histories.
The facility failed to maintain an infection prevention and control program, leading to incidents where an LVN did not change gloves between tasks, a resident on contact isolation lacked proper signage, and housekeeping staff entered without PPE. Additionally, there were no biohazard or soiled laundry bins in the isolation room.
A resident with COPD and respiratory failure received oxygen at 4.0 Lpm instead of the physician-ordered 2 Lpm. Despite ongoing monitoring, the incorrect setting was observed, and staff interviews confirmed that the resident sometimes adjusted the oxygen settings herself.
A deficiency was identified in the pharmaceutical services provided to a resident receiving Zoloft and olanzapine. The care plan required strict monitoring for adverse reactions due to serious risks associated with these medications. However, the report suggests potential lapses in adhering to these monitoring protocols, leading to the noted deficiency.
A resident with Alzheimer's and dementia was administered Risperdal twice daily for vascular dementia, contrary to facility policy and standard medical guidelines. Interviews with staff confirmed the improper use of antipsychotics for such diagnoses, and attempts to contact the prescribing NP and MD were unsuccessful.
The facility failed to provide a safe and functional environment, with issues including non-functioning cold water in a resident's bathroom and cigarette butt litter in the designated smoking area. The Maintenance Director forgot to turn the water valve back on after repairs, and the Housekeeping Manager lacked a tracking log for cleaning the smoking area.
A resident with moderate cognitive impairment eloped from the facility undetected on multiple occasions by removing her wander guard bracelet. Despite being placed on 1:1 supervision and having a new wander guard applied, the resident managed to elope again, posing a significant risk to her safety. The facility conducted in-services on elopement prevention, but the measures were insufficient to prevent the incidents.
Failure to Obtain Physician Order for Enhanced Barrier Precautions at Admission
Penalty
Summary
Surveyors identified a deficiency in that the facility failed to obtain physician orders for a resident’s immediate care related to Enhanced Barrier Precautions (EBP) at the time of admission. The resident was an older male admitted with multiple significant diagnoses, including cerebral infarction, metabolic encephalopathy, dysphagia, cognitive communication deficit, muscle wasting and atrophy, and gastrostomy status with a feeding tube in place. The resident’s MDS showed severe cognitive impairment with a BIMS score of 4 and documented use of a feeding tube on admission. The baseline care plan indicated the resident required tube feeding and was dependent on staff for tube feeding and water flushes, and the order summary reflected an active enteral feeding order starting on the admission date. Record review showed that from admission through several days afterward, there were no physician orders for EBP, despite the resident having a feeding tube, which the facility’s policy defined as an indwelling medical device requiring an EBP order. The DON stated that the resident required EBP since admission due to the feeding tube and acknowledged that no EBP order was in place, although staff were aware of and followed EBP. The ADON confirmed that residents with feeding tubes required EBP because the tube was an invasive device and that the team was supposed to review physician orders for accuracy. The Administrator also stated that residents with feeding tubes needed EBP orders and that the team reviewed new admission orders to ensure they were in place. The facility’s EBP policy specified that an order for EBP would be obtained for residents with wounds or indwelling medical devices, including feeding tubes, even if they were not known to be infected or colonized with MDROs.
Baseline Care Plan Omitted Enhanced Barrier Precautions for Tube-Fed Resident
Penalty
Summary
Surveyors identified a failure to develop and implement a complete baseline care plan within 48 hours of admission for one resident, specifically omitting enhanced barrier precautions (EBP) despite the presence of an indwelling device. The resident was an older male admitted with multiple diagnoses including cerebral infarction, metabolic encephalopathy, dysphagia, cognitive communication deficit, muscle wasting and atrophy, and gastrostomy status, and had a BIMS score of 4 indicating severe cognitive impairment. The MDS reflected use of a feeding tube on admission, and the order summary showed an active enteral feeding order with Glucerna 1.5 via feeding tube at a specified rate every shift. The baseline care plan documented that the resident required tube feeding and was dependent for tube feeding and water flushes, but directed staff to see orders for current feeding orders and did not include EBP. Interviews with facility leadership confirmed that the resident required EBP from admission due to the feeding tube being considered an indwelling or invasive device. The DON stated that the baseline care plan was completed within 48 hours and that she reviewed and signed it, but acknowledged that the section asking whether the resident required special precautions was marked “no,” resulting in EBP not being reflected on the baseline care plan. The ADON and ADM both stated that residents with feeding tubes should have EBP noted on the baseline care plan and that EBP should have been included for this resident. The facility’s Baseline Care Plans policy required development and implementation of a baseline care plan within 48 hours of admission that includes the minimum healthcare information necessary to properly care for a resident, but the omission of EBP from the resident’s baseline care plan did not meet this standard.
Failure to Implement and Communicate Droplet Precautions for an Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to fully implement droplet transmission-based precautions for a cognitively impaired male resident who was readmitted from the hospital with rhino virus/possible flu and pneumonia and required droplet precautions. The resident had multiple diagnoses including TIA, hypertension, dementia, and dysphagia, and was dependent on staff for all self-care. His care plan reflected Enhanced Barrier Precautions (EBP) for prior conditions, including use of gown and gloves for high-contact care and optional mask/eye protection as indicated. Upon readmission, baseline/readmission documentation and hospital paperwork indicated that he required droplet precautions, and a nursing progress note documented that he was on single-room isolation. Orders were entered for droplet precautions due to influenza. Despite this, surveyor observation on the morning after readmission showed that there was no droplet/isolation sign posted at the resident’s door and no PPE set up outside the room until after 8:40 a.m., when staff were seen placing the sign and hanging PPE. Multiple CNAs and nurses reported that, although some staff verbally knew the resident was on droplet precautions and individually obtained PPE from carts or the nurses’ station, the standardized visual cues and room setup (signage and PPE station) were not in place during the night and early morning. One CNA reported providing incontinence care around 6:30 a.m. wearing only gown and gloves based on the resident’s prior EBP status and stated she was not informed of droplet isolation until later that morning; she also reported having entered multiple rooms and assisted with breakfast before learning of the droplet status. Another CNA assigned to the hallway overnight stated there were no isolation signs or PPE set up at the door while she worked, although she personally used mask, shield, gown, and gloves based on verbal report. Interviews with nursing staff and leadership revealed inconsistent understanding and execution of responsibilities for initiating and posting droplet precautions. One LVN who assisted with admission stated she knew from hospital report that the resident was on droplet precautions and used full PPE for the skin assessment but did not place signs or PPE at the door and could not recall if they were present. Another LVN on night shift stated she was aware of the droplet order, wore appropriate PPE, and verbally informed CNAs and a lab technician, but confirmed that signs and PPE were not posted at the door and cited limited access to certain supplies at night. A day-shift RN acknowledged that when he arrived, there were no precautions posted and that the admitting nurse was responsible for setting them up. The DON and Administrator both stated that when a resident is admitted or readmitted on droplet precautions, appropriate signage and PPE should be in place immediately based on hospital report and that nurses are responsible for clarifying isolation type and informing staff. The facility’s infection prevention and control policy requires that residents with communicable diseases be placed on transmission-based precautions per CDC guidelines and that staff use PPE according to policy, but in this case, the facility did not ensure that all staff were informed of the resident’s droplet status and did not ensure that droplet precaution signage was posted at the room entrance during the period the resident was on droplet precautions.
Failure to Document Physician-Ordered 1:1 Observation in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who had physician orders for 1:1 constant observation every hour due to aggressive behaviors associated with vascular dementia and psychosis. The resident's care plan and physician orders specified that hourly monitoring was required, including during all activities, toileting, and sleeping, for a period of 72 hours. However, review of the Medication Administration Record (MAR) revealed that documentation of this monitoring was missing for a six-hour period on a specific date. Interviews with staff indicated that the assigned nurse was responsible for both performing and documenting the 1:1 observation during the time in question. The nurse confirmed that the monitoring was completed but acknowledged that she did not sign the MAR as required by facility policy, which states that documentation should be completed at the time of service. The nurse also stated that she believed another nurse might sign off, but clarified that the person performing the monitoring should be the one to document it. The Director of Nursing (DON) confirmed the omission on the MAR and stated that the facility's policy requires timely and accurate documentation of care. The DON also noted that monitoring was performed during the unsigned period, but the lack of documentation meant there was no official record of compliance with the physician's order. Facility records showed that the nurse responsible had received recent training on documentation, but the required entries were still not made in this instance.
Unqualified Activity Director Leads to Deficiency in Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required by regulations. Record review showed that the current Activity Director (AD) was not certified and did not meet the state requirements for the position, which include being licensed or registered, eligible for certification as a therapeutic recreation specialist or activities professional, having two years of relevant experience, or being a qualified occupational therapist or occupational therapy assistant. The AD had no previous experience in the role and had not yet enrolled in an approved AD program, despite being hired several months prior. The AD stated she had submitted paperwork and fees to enroll in an online program but was not officially enrolled as of the date of the survey. Interviews with the HR Coordinator and Administrator confirmed that the AD was not certified and had not met the qualifications outlined in the facility's job description or state requirements. The Administrator acknowledged responsibility for ensuring the AD enrolled in a program within six months of hire, as stipulated in a written agreement, but this had not occurred by the time of the survey. The facility did not have a policy on the requirements for an AD, only a job description, and all 61 residents were affected by the lack of a qualified professional directing the activities program.
Failure to Include Essential Medications in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included essential medication instructions for a resident within 48 hours of admission, as required by facility policy. Specifically, the baseline care plan for a female resident with multiple diagnoses, including Type 2 Diabetes Mellitus and Peripheral Arterial Disease, did not include her prescribed insulin and anticoagulant medications, despite physician orders and administration records confirming their use. The omission was confirmed through record review and interviews with staff, including the MDS nurse, LVN, and DON, all of whom acknowledged that such medications should be included in the baseline care plan to ensure proper care. The resident's admission records indicated she was cognitively intact and had significant medical needs requiring careful medication management. The facility's own policy and staff interviews confirmed that baseline care plans must include all necessary medications and be completed within 48 hours of admission. However, the review of the resident's baseline care plan showed that insulin and anticoagulant medications were not documented, and this was acknowledged by the DON during the survey. The failure to include these medications in the baseline care plan constituted a deficiency in meeting professional standards of quality care.
Failure to Provide Required Two-Person Assistance During Bed Bath
Penalty
Summary
A deficiency occurred when a resident with paraplegia, severe cognitive impairment, and total dependence for bathing was given a bed bath by only one CNA, despite her care plan and MDS assessment specifying the need for assistance from two staff members. The resident was observed receiving a bed bath from a single CNA, with the resident uncovered and the bath water present, confirming that the care was being provided by only one staff member at that time. Interviews with the CNA involved and other staff confirmed that the resident was known to require two-person assistance due to her physical and behavioral needs, including a history of hitting and kicking during care. Staff interviews revealed inconsistent understanding and practices regarding when two-person assistance was required. Some CNAs relied on the Kardex, care plan, or verbal instructions from nurses to determine the level of assistance needed, while others mentioned that the need for two-person assistance could depend on the resident's behavior at the time. There was also uncertainty about the frequency and content of in-service training related to one- or two-person assists, with some staff recalling recent training and others unsure about when it last occurred. The facility's leadership, including the DON and Administrator, confirmed that the care plan and Kardex should be checked to determine the required level of assistance, and that nurses are responsible for monitoring and communicating changes to CNAs. However, it was noted that there was no specific policy on supervision, use of the Kardex, or CNA responsibilities regarding one- or two-person assists. This lack of clear policy and inconsistent staff practices led to the resident not receiving the required level of supervision and assistance during a bed bath.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours on one day during the review period. Record review of RN timesheets showed that on a Saturday, the facility only had RN coverage for 3.91 hours instead of the required 8 consecutive hours. The Director of Nursing (DON) acknowledged responsibility for ensuring RN coverage and stated that if the scheduled RN was unavailable, it was her or the Assistant Director of Nursing's (ADON) responsibility to find coverage or cover the shift themselves. However, the DON could not recall the specific circumstances that led to the shortfall on the identified day and noted that if she or the ADON had covered the remainder of the shift, it would not have been documented since they are salaried and not required to clock in. The facility's policies require RN coverage for at least 8 consecutive hours per day, 7 days a week, and include the DON's hours toward this requirement. Both the DON and the Administrator confirmed their understanding of the policy and acknowledged the potential for certain RN-specific tasks to go unperformed when coverage is lacking. The Administrator also stated that it was ultimately her responsibility to ensure compliance with RN staffing requirements and that the facility had sufficient RNs to meet the coverage requirement, despite the documented lapse.
Failure to Ensure Drug Regimen Free from Unnecessary Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of risperidone (Risperdal), an antipsychotic medication. The resident in question was an elderly female with diagnoses including paraplegia, mood disorder, and schizoaffective disorder. Her medical records, including the face sheet and MDS assessment, reflected severe cognitive impairment and the use of antipsychotic and antidepressant medications. The care plan documented the use of Risperdal for symptoms related to schizophrenia, such as mood changes and yelling, and included monitoring for adverse reactions and pharmacy review per facility policy. Upon review, it was found that the medical diagnosis supporting the use of Risperdal was inconsistently documented. While the care plan and some physician notes referenced schizophrenia or schizoaffective disorder, the official medical diagnosis in the resident’s records did not consistently reflect this until the day of the survey. The nurse practitioner and DON confirmed that the diagnosis of schizophrenia was only present in certain notes and the order entered into the electronic charting system, but not in other official paperwork. The diagnosis was added to the medical record on the day of the survey, and the nurse practitioner clarified that the correct diagnosis should be schizoaffective disorder, as originally given by the primary care provider. Interviews with facility staff, including the DON and LVN, revealed that medication orders are entered and double-checked by nursing staff, but if the wrong diagnosis is entered, it could result in an inappropriate medication regimen. The lack of a consistent and adequate indication for the use of Risperdal in the resident’s official medical record led to the finding that the facility failed to ensure the resident’s drug regimen was free from unnecessary drugs.
Inaccurate Documentation of Psychiatric Diagnosis in Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident diagnosed with schizoaffective disorder. Documentation inconsistencies were found in the resident's medical record, with some parts inaccurately listing schizophrenia as the diagnosis instead of schizoaffective disorder. The resident's face sheet and several clinical assessments correctly identified schizoaffective disorder, but the care plan, physician orders, and some nurse practitioner notes referenced schizophrenia. The discrepancy was confirmed during interviews with the DON and NP, who acknowledged that the original diagnosis was schizoaffective disorder, but schizophrenia had been documented in various parts of the record, including the care plan and medication orders. This documentation error resulted in the resident's clinical records not being maintained in accordance with accepted professional standards and practices. The resident, who had a history of paraplegia, mood disorder, and schizoaffective disorder, was receiving antipsychotic medication (Risperdal) for her condition. The inaccurate documentation could affect the appropriateness of care provided, as the care plan and medication orders were not aligned with the resident's actual diagnosis as established by the primary care provider.
Failure to Provide Prescribed Pain Medication Due to Lapses in Pharmaceutical Services
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident with a history of left below-knee amputation, peripheral vascular disease, type 2 diabetes with hyperglycemia, and cellulitis. The resident had an active order for Acetaminophen-Codeine Tablet 300-30 mg to be administered every six hours for pain, but missed three doses due to the medication not being available. Nursing staff did not ensure the prescription was filled in a timely manner, and the resident was instead given Tylenol 500 mg without a corresponding order being entered into the electronic medical record. The resident reported being in pain and questioned the nurse about the medication provided, noting that the pill given did not match the usual appearance of his prescribed pain medication. Despite the resident's repeated inquiries, the nurse assured him it was the correct medication. The nurse later admitted to giving Tylenol 500 mg instead of the prescribed Acetaminophen-Codeine and signing off on the medication administration record for the wrong medication. The nurse also failed to notify supervisors or access the emergency medication supply system (cubex) when the prescribed medication was unavailable. Interviews with facility staff revealed that the process for reordering controlled medications required a new prescription from the prescriber, and that staff were trained to access emergency supplies or notify supervisors if medications were not available. However, in this instance, the nurse did not follow these procedures, resulting in the resident missing prescribed doses and receiving an unprescribed substitute medication. The incident was only brought to the attention of facility leadership after the resident filed a grievance.
Failure to Accurately Document and Administer Ordered Pain Medication
Penalty
Summary
A deficiency occurred when a resident with a history of left below-knee amputation, peripheral vascular disease, type 2 diabetes with hyperglycemia, and cellulitis of the right lower limb did not have complete and accurate documentation of medication administration. The resident had a physician's order for Acetaminophen-Codeine Tablet 300-30 mg to be given every six hours as needed for pain, but missed three doses over two days. The Medication Administration Record (MAR) did not accurately reflect the administration of the ordered medication, and the resident reported receiving a different medication than what was prescribed. The resident reported experiencing significant pain and requested his usual pain medication, but was given Tylenol 500 mg instead of the ordered Acetaminophen-Codeine. The nurse administering the medication confirmed she provided Tylenol 500 mg because the prescribed medication was not available, and she did not inform anyone about the shortage or document the administration of Tylenol 500 mg in the MAR. The nurse also mistakenly signed off in the MAR as if the resident had received the Acetaminophen-Codeine, and failed to add the Tylenol 500 mg order to the electronic medical record. Interviews with facility staff revealed that the nurse did not access the emergency medication supply system or notify supervisors about the unavailability of the prescribed medication. The Director of Nursing and the administrator were not aware of the incident until the resident filed a grievance. The facility's policy required medications to be administered as ordered and documented accurately, but this was not followed in this case, resulting in incomplete and inaccurate medical records for the resident.
Failure to Obtain Proper Medication Consents
Penalty
Summary
The facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for three residents who were reviewed for resident rights. Specifically, Resident #36 did not have signed and dated consents for psychotropic medications such as Risperdal, clonazepam, buspirone, fluvoxamine, or Wellbutrin XL ER. The consent for Risperdal was signed by the resident instead of the responsible party (RP) and was not dated. This oversight was noted despite the resident having a diagnosis of Alzheimer's Disease, dementia, and other conditions that impair cognition, as indicated by a BIMS score of 09, showing moderately impaired cognition. Similarly, Resident #7 did not have signed and dated consents for psychotropic medications including clonazepam, buspirone, Seroquel, Paxil, and Trazadone. The consents were signed by the resident instead of the RP and were undated. Additionally, there was no consent form for clonazepam. Resident #7 had a diagnosis of chronic obstructive pulmonary disease (COPD), respiratory failure, hypertension, chronic kidney disease, schizophrenia, type 2 diabetes mellitus, and epilepsy, with a BIMS score of 09, indicating moderately impaired cognition. Resident #38 also did not have properly completed consent forms for antipsychotic and antidepressant medications. The consent form for Olanzapine did not have the medication name, was not dated, and was signed by the resident who had a responsible party and was cognitively unable to sign the consent form. There was no consent form for Zoloft. Resident #38 had diagnoses including bipolar disorder and major depressive disorder, with a BIMS score of 00, indicating severe cognitive impairment. Interviews with the DON and LVN B revealed that the process for obtaining and documenting consents was not consistently followed, leading to these deficiencies.
Failure to Maintain Proper Consent Forms for Medications
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for three residents reviewed for pharmacy services. Specifically, the facility did not ensure that consent forms were properly completed or signed by a responsible party prior to the administration of antipsychotic and antidepressant medications. This deficiency was identified for three residents, each with significant cognitive impairments and complex medical histories, including bipolar disorder, major depressive disorder, Alzheimer's disease, and schizophrenia. For Resident #38, the facility did not have a consent form for the medication Zoloft, and the consent form for Olanzapine was incomplete, lacking the medication name, date, and proper signature from the responsible party. Resident #38 had severe cognitive impairment and was unable to provide informed consent, yet the consent form was signed by the resident instead of the responsible party. The responsible party for Resident #38 confirmed that they were not aware of signing any consent forms for the medications. Resident #36's records revealed that consent forms for multiple medications, including Fluvoxamine, Bupropion, Clonazepam, and Wellbutrin, were either missing or improperly signed by the resident instead of the responsible party. Similarly, Resident #7's consent forms for several medications, including Buspirone, Clonazepam, Seroquel, Paxil, and Trazadone, were signed by the resident and not the responsible party, with some forms undated. The Director of Nursing acknowledged the oversight and indicated that consent form audits were conducted monthly but would now be performed weekly. However, there was no policy in place for consent forms at the time of the survey.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to several deficiencies. One incident involved an LVN who did not change gloves after touching a resident's remote before performing a glucose check and administering insulin. This failure to follow proper hand hygiene and glove-changing protocols was acknowledged by the LVN and the DON, who both recognized the risk of cross-contamination and infection spread due to these actions. Another deficiency was observed with a resident who was supposed to be on contact isolation due to an ESBL urinary tract infection. The facility did not place the required contact precautions signage outside the resident's room, and housekeeping staff entered the room without donning PPE. The housekeeping staff member admitted to forgetting to wear PPE and was unaware of the potential consequences. Additionally, there were no biohazard or soiled laundry bins in the resident's room to dispose of PPE and soiled linens, which was confirmed by the Housekeeping Manager and the DON. The facility's infection prevention and control program, as outlined in their policy, mandates the use of PPE, adherence to safe injection practices, and proper isolation protocols. However, the observed deficiencies indicate a failure to implement these policies effectively. Staff interviews revealed a lack of awareness and adherence to these protocols, contributing to the risk of infection spread within the facility.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care was provided with professional standards of practice. Specifically, Resident #7's oxygen was administered at 4.0 Lpm instead of the physician-ordered 2 Lpm via nasal cannula. This discrepancy was observed on 03/26/24 when the resident's oxygen concentrator was set at 4 Lpm, despite the order for 2 Lpm. Interviews with the nursing staff revealed that Resident #7 sometimes adjusted the oxygen settings herself, and the nurses were continually monitoring it. However, the incorrect setting was still found during the surveyor's observation. Resident #7, a [AGE] year old female with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure, was admitted to the facility on 12/22/22. Her care plan included interventions for respiratory distress and oxygen use as ordered. Despite these measures, the facility's failure to maintain the correct oxygen setting as per the physician's order was evident. The Director of Nursing (DON) confirmed that oxygen settings are checked by nurses every shift, but the discrepancy in oxygen administration was still noted, indicating a lapse in adherence to the prescribed care plan.
Deficiency in Pharmaceutical Services and Monitoring
Penalty
Summary
The report identifies a deficiency in the pharmaceutical services provided to a resident who is receiving antidepressant medication (Zoloft) for major depressive disorder and antipsychotic medication (olanzapine) for bipolar disorder. The care plan includes administering these medications as ordered by the physician and monitoring for side effects and effectiveness every shift. However, the report highlights the presence of black box warnings for both medications, indicating serious risks such as increased suicidality in young adults for Zoloft and increased mortality in elderly patients with dementia-related psychosis for olanzapine. The care plan also includes detailed instructions for monitoring and documenting adverse reactions, but it is unclear if these protocols were adequately followed or if the necessary monitoring was consistently performed, leading to the deficiency noted by the surveyors. The resident's care plan specifies the need to monitor and report any adverse reactions to the medications, including changes in behavior, mood, cognition, and physical symptoms such as unsteady gait, muscle cramps, and gastrointestinal issues. The report does not provide specific instances of adverse reactions or failures in monitoring but emphasizes the critical nature of these monitoring activities due to the severe risks associated with the medications. The deficiency appears to stem from potential lapses in adhering to the care plan's requirements for vigilant monitoring and documentation of the resident's response to the medications, which is essential for ensuring their safety and well-being.
Failure to Ensure Drug Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, specifically for one resident who was administered Risperdal, an antipsychotic medication, twice daily for vascular dementia. The resident, a male with a diagnosis of Alzheimer's Disease and dementia, was admitted to the facility and had a BIMS score indicating moderately impaired cognition. Despite the facility's policy against using psychotropic drugs unless necessary to treat a specific condition, the resident's care plan included Risperdal for vascular dementia, which is not an appropriate indication for antipsychotic use according to the facility's policy and standard medical guidelines. Interviews with facility staff, including an LVN and the DON, confirmed that antipsychotics should not be prescribed for residents with Alzheimer's or dementia due to the associated risks and black box warnings. The facility's records showed that the resident received Risperdal consistently from February through March, and attempts to contact the prescribing NP and MD for clarification were unsuccessful. The facility's policy on psychotropic medication, implemented in August 2022, was not adhered to in this case, leading to the administration of an unnecessary drug to the resident.
Environmental Safety and Cleanliness Deficiencies
Penalty
Summary
The facility failed to provide a safe and functional environment for residents, staff, and the public in one of the resident rooms and the designated smoking area. Specifically, the cold water in a resident's bathroom was not functioning due to the Maintenance Director forgetting to turn the valve back on after repairs. The ADON, who was responsible for checking the functionality of the water, verbally informed the Maintenance Director but did not input a work order into the system. The resident affected did not notice the lack of cold water and stated it did not affect him. The Administrator confirmed there was no policy on the environment. Additionally, the designated smoking area was found to be littered with cigarette butts in a trash can and a planter pot, which were not the designated disposal areas. The trash can was rusted and lacked a functioning lid. The Maintenance Director and Housekeeping Manager acknowledged the issue, with the Housekeeping Manager stating that the area is cleaned every other day but without a tracking log. The Administrator confirmed that housekeeping is responsible for cleaning the area twice a week and acknowledged the absence of a check-off list for documentation.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who eloped from the facility undetected on multiple occasions. Resident #44, who had a history of moderate cognitive impairment and various medical conditions, was able to remove her wander guard bracelet and exit the facility on two separate occasions. The first elopement occurred on 05/05/23, when the resident was found walking outside the facility by a dietary aide and was subsequently redirected back inside by an LVN. Despite being placed on 1:1 supervision for 72 hours and having a wander guard bracelet applied, the resident managed to elope again on 06/24/23 and 06/26/23 by removing the bracelet undetected each time. On 06/24/23, Resident #44 was found outside the building in the front patio without her wander guard bracelet, which she had placed in a drawer. A new wander guard was applied, but the resident eloped again on 06/26/23 and was found approximately 0.2 miles away from the facility by a busy intersection. The facility staff, including the DON and LVNs, conducted interviews and reviewed records, but were unable to determine how the resident managed to remove the wander guard bracelet. The resident was placed on 1:1 supervision for another 72 hours following the second elopement. The facility conducted in-services with staff on elopement prevention and monitoring residents with exit-seeking behaviors. Despite these measures, the facility's failure to provide adequate supervision and ensure the effectiveness of the wander guard bracelet led to multiple elopements by Resident #44, posing a significant risk to her safety. The resident was eventually discharged home with family on 06/27/23 after the second elopement incident.
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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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