Woodland Manor Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Conroe, Texas.
- Location
- 99 Rigby Owen Rd, Conroe, Texas 77304
- CMS Provider Number
- 675229
- Inspections on file
- 40
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 10 (3 serious)
Citation history
Health deficiencies cited at Woodland Manor Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure food was safely and properly prepared when several residents were served BLT sandwiches containing undercooked bacon that appeared translucent, pale, and limp, with photos showing a single fatty strip of bacon on white bread and minimal lettuce. One resident with hemiplegia and dysphagia reported immediately notifying the cook and questioning the safety of the meat, while another resident with DM and a foot ulcer described the meal as their primary evening meal and reported that kitchen staff "threw anything together" and responded dismissively when challenged about the bacon’s doneness. A third resident with CKD and dementia agreed with these concerns and characterized the kitchen negatively. The DA acknowledged the incident and stated the bacon was cooked less crispy due to chewing issues for some residents, while the DM and DON later reviewed photos and described the bacon as undercooked and unfit to eat, contrary to the facility’s Food Handling policy requiring food to be of good quality, safe for consumption, and handled per food codes and HACCP guidelines.
A hospice resident with severe cognitive impairment, multiple comorbidities, a history of falls, and on an anticoagulant was found on a floor mat by the DON, who was working as a floor nurse. Despite facility policy defining such an event as a fall and requiring a head-to-toe assessment, vital signs, neuro checks for unwitnessed falls, documentation, and notification of the physician, family, DON, supervisor, and hospice, the DON did not complete a post-fall assessment, did not obtain vital signs or neuro checks, did not document the event, and did not notify the physician, hospice, or resident representative. Other staff, including an RN, NP, MD, and therapy staff, confirmed they were not informed of the fall and that no fall-related documentation existed in the record, even though the hospice agreement required immediate notification of condition changes. The resident subsequently experienced a rapid neurological and respiratory decline and died at the facility, and surveyors cited an Immediate Jeopardy deficiency related to failure to recognize and manage the unwitnessed fall according to policy.
Staff failed to assess, monitor, and document care for a resident on anticoagulant therapy who was found on the floor after an unwitnessed fall. The DON, acting as floor nurse, had the resident assisted back to bed but did not complete a head-to-toe assessment, pain assessment, post-fall assessment, neuro checks, vital signs, SBAR, progress note, or incident report, and did not notify the physician, hospice, or the resident’s representative, despite facility policy defining any unwitnessed event with the resident on the floor as a fall requiring these actions. The resident, who had vascular dementia, was fully dependent for ADLs, had a prior fall history, and was receiving Eliquis, subsequently exhibited pain and a rapid neurological and respiratory decline before expiring, while the fall was never entered into the incident/accident log and the anticoagulant was not incorporated into the care plan.
The facility failed to follow its abuse and incident reporting policies by not reporting multiple allegations of neglect, misappropriation, and sexual abuse to the State Survey Agency within required timeframes. In one case, a dependent, cognitively impaired resident with a history of falls was found on the floor by the DON, who did not perform a post‑fall assessment, obtain vitals, complete required documentation, or notify the physician, hospice, responsible party, or administrator; the neglect related to this unwitnessed fall and the resident’s subsequent decline and death was not reported. In another case, a resident with dementia reported a missing debit card and suspected a former roommate; the ADON notified leadership, but the Abuse Coordinator/administrator did not report the allegation to the state or conduct an investigation, and the card was never found. In a third case, a cognitively impaired resident alleged sexual assault when a roommate with dementia repeatedly entered the bathroom and watched her while toileting; staff documented the allegation, separated the residents, and police were called by the resident, but the allegation of sexual abuse was never reported to the state despite policy and regulatory requirements.
The facility failed to follow its abuse, neglect, and exploitation policies in three separate cases involving vulnerable residents. In one case, a dependent, cognitively impaired resident at high risk for falls was found on the floor by the DON, who did not perform a post-fall assessment, obtain VS or neuro checks, document the event, notify the MD, hospice, or family, or initiate an investigation, even though the event was unwitnessed and the resident later experienced a rapid neurological and respiratory decline and died. In a second case, a cognitively impaired resident reported a missing debit card and suspected a former roommate; although the ADON notified leadership, the Abuse Coordinator/administrator did not initiate or document any investigation into possible misappropriation, and the card was never found. In a third case, a cognitively impaired resident with bipolar disorder repeatedly complained that a roommate with dementia entered the bathroom, watched her while toileting, and once pushed aside a wheelchair she used to barricade the door; the resident called police and alleged sexual assault, staff separated the roommates, but there was no evidence of a formal abuse investigation or comprehensive assessment as required by facility policy.
Multiple cognitively intact residents on regular or therapeutic diets reported that fried fish served at a lunch meal was consistently overcooked and inedible, with two residents in the dining room demonstrating the hardness of the fish by tapping it on the table and leaving most or all of it uneaten, while another resident declined the facility tray and ate restaurant food instead. The cook stated he began frying the fish well before service, held it on the steam table, and later reheated it when temperatures dropped, acknowledging that this may have caused overcooking. These observations and interviews showed that the facility failed to provide palatable, attractive food at a safe and appetizing temperature as required by its own food preparation policy.
A resident with diabetes and diabetic neuropathy had a physician order for a low concentrated sweets therapeutic diet, but the care plan continued to list a regular diet and did not specify the ordered diet type. The MDS triggered a therapeutic diet, and the care plan under Nutritional Status focused on maintaining stable weight and general dietary approaches without incorporating the current diet order. Facility leadership and clinical staff acknowledged that all residents should have comprehensive person-centered care plans and that this resident’s plan did not reflect the prescribed therapeutic diet, despite policy requiring care plans to include measurable objectives and services to meet each resident’s needs.
Two residents who were dependent for showers and at risk for pressure ulcers did not receive scheduled baths/showers as outlined in their care plans, despite one resident exhibiting oily hair and poor oral hygiene and another reporting he only received a weekly shower and had not been bathed that week. Shower documentation for one resident was missing, and the other had no recorded shower for an extended period. CNAs and nursing staff reported that hall relocations, limited CNA staffing, lack of night-shift participation in bathing, and reliance on an intermittently available shower CNA made it difficult to complete all scheduled showers, even though facility policy required regular bathing and nursing oversight via shower sheets.
Surveyors found that required daily nurse staffing information was not posted in the lobby as required, leaving the designated placard area empty during a morning observation. The facility’s policy required that a daily Nurse Staffing Sheet with the current date, census, and RN, LVN, and CNA staffing numbers and hours be posted at the beginning of each shift in a prominent, accessible location. The DON and ADON, who shared responsibility for updating the posting, reported that a morning meeting and patient-related duties delayed completion of the staffing sheet, resulting in the information not being available to visitors and others during that time.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
A resident with severe cognitive impairment was found on the floor, and the facility failed to conduct a head-to-toe assessment to check for injuries before moving him. Despite the facility's policy and professional standards, the LVN did not perform the necessary assessment, citing family pressure. Interviews with staff confirmed the requirement for such assessments to ensure resident safety.
A resident with severe cognitive impairment was improperly lifted off the floor by staff using his arms instead of a mechanical lift, contrary to the facility's safety procedures. This action was inconsistent with the resident's care plan and staff training, potentially risking injury.
The facility failed to provide scheduled showers and grooming for four residents, impacting their dignity and quality of life. A male resident with severe cognitive impairment did not receive his scheduled showers and grooming, resulting in an unkempt appearance. A female resident with moderate cognitive impairment missed her scheduled shower, leaving her feeling unclean. Another male resident with kidney failure did not have a care plan for bathing and missed his shower. A male resident with multiple sclerosis also missed his scheduled showers. Staffing shortages and the elimination of a dedicated shower technician contributed to these failures.
A facility failed to provide necessary hygiene and grooming services to residents unable to perform ADLs independently. Several residents did not receive scheduled showers, and some were not groomed as per their care plans. Staffing challenges and the elimination of a dedicated shower technician position contributed to this deficiency, impacting residents' dignity and rights.
Undercooked Bacon Served on BLT Sandwiches
Penalty
Summary
The deficiency involves the facility’s failure to ensure food was palatable, attractive, and safely prepared, specifically related to undercooked bacon served on BLT sandwiches to three residents during a dinner meal. Resident #1, an older female with hemiplegia, dysphagia, a tooth infection, and morbid obesity, reported receiving a BLT with a piece of bacon she described as raw and very fatty. She stated she immediately informed the dietary cook (DC) and questioned him about the health impact of consuming raw pork, and he did not know the answer. A photo on her cellphone taken at the time showed a single piece of bacon on the sandwich with more than half of the strip composed of fat that appeared translucent clear and tan in color. Resident #2, an older male with diabetes mellitus with a foot ulcer, depression, and inappropriate diet and eating habits, and Resident #3, an older female with stage 2 chronic kidney disease, dementia, and unsteadiness on her feet, also reported being served raw bacon on their BLT sandwiches during the same dinner meal. Resident #2 stated he received only one piece of bacon on his sandwich and was upset because this was supposed to be his evening meal. He reported that the dietary aide (DA) and DC did not care and would “throw anything together.” He further stated that when he asked the DC if he would eat or pay for bacon prepared that way, the DC responded that Resident #2 did not pay for it either, which Resident #2 found disrespectful. Resident #3 agreed with Resident #2’s statements and described the kitchen as horrible. Photographic evidence provided by Resident #2 showed one piece of bacon on white bread with a few pieces of lettuce pushed to the side, and a second photo showed bacon with fatty portions that appeared completely translucent and lean portions that were gray or pale pink and limp, with the end curling over the plate edge. The DA, who had worked at the facility for 5–6 years, acknowledged an incident where residents complained of being served raw bacon and stated the DC did not cook the bacon crispy because some residents were on special diets and had difficulty chewing; he said he tasted the bacon and felt it was not as crispy as normal but did not believe it was raw. The Dietary Manager (DM), after seeing Resident #1’s photo, stated the bacon should have been cooked longer and that bacon must be cooked all the way through using a thermometer rather than visual appearance. The DON, who started shortly after the incident, reviewed the photo and described the bacon as raw, terrible, and unfit to eat. The facility’s written Food Handling policy required that all food be of good quality and safe for consumption and handled according to state and U.S. Food Codes and HACCP guidelines, which was not followed in this instance.
Failure to Notify Physician and Hospice and Complete Post-Fall Assessment After Unwitnessed Fall in Anticoagulated Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician, hospice provider, and resident representative after an unwitnessed fall, and failure to complete required post-fall assessments and documentation. A cognitively impaired, bed- and wheelchair-dependent female resident with multiple diagnoses, including hypertension, type 2 diabetes, vascular dementia, and a history of falls, was admitted on hospice and was prescribed an anticoagulant (blood thinner). Her care plan and MDS documented that she was at risk for falls related to impaired mobility, used a wheelchair, required total assistance with ADLs, had severe cognitive impairment (BIMS score of 00), and was on oxygen therapy for shortness of breath. The facility’s fall policy defined a fall as any event in which an individual unintentionally comes to rest on the floor or ground, including when a resident is found on the floor without a witness, and required evaluation for injuries, vital signs, neuro checks for unwitnessed falls, and notification of the physician, family, DON, nursing supervisor, and other appropriate team members. On the day of the incident, the DON was working as a floor nurse from 6 a.m. to 6 p.m. and found the resident on a fall mat on the floor in her room sometime between 4 p.m. and 5 p.m. The DON acknowledged that the resident was a known fall risk with a history of falls. A CNA reported that the DON requested assistance to move the resident from the floor back to bed, that the resident denied falling, and that there were no visible injuries at that time. The DON stated she assessed the resident for pain because she was found on the floor and because it was shift protocol, but she did not document this pain assessment. She further admitted that she did not complete a head-to-toe assessment, post-fall assessment, progress note, SBAR, incident report, neurological checks, or obtain vital signs after the unwitnessed fall, despite the resident being on an anticoagulant and facility protocol requiring these actions for unwitnessed falls. The DON also stated that she did not notify the primary physician, hospice nurse, resident representative, Administrator, or other medical personnel because she did not consider the resident being on the floor mat as a fall, even though the facility’s fall policy defined a fall to include residents found on the floor. She reported she was not aware the resident was on a blood thinner, although she described the facility protocol for unwitnessed falls in residents on anticoagulants as including calling the doctor and hospice and monitoring for bleeding with neuro checks. Other staff, including an LVN, the NP, the MD, the hospice RN, the CCM/MDS coordinator, and the Administrator, all confirmed they were not notified of the unwitnessed fall and stated they would have expected notification per policy and would have performed or directed further assessment had they been informed. Facility records contained no documentation of the unwitnessed fall, no progress notes related to the event between the relevant dates, and no evidence that the physician or hospice were notified at the time of the fall, despite the hospice agreement requiring the facility to immediately inform hospice of any change in condition suggesting a need to alter the plan of care. The resident later experienced a rapid neurological and respiratory decline and ultimately expired at the facility, and an Immediate Jeopardy was identified related to the failure to notify and assess after the unwitnessed fall. Additional interviews reinforced that the facility’s own policies and staff expectations were not followed in this case. An LVN reported that the resident had been receiving PRN Tramadol for pain and that the family had instructed staff to interpret facial grimacing as a sign of pain; she also noted the resident’s decline in activity and intake around the time of the incident. The hospice wound care nurse had given orders to start comfort care due to fluid-filled lungs and elevated temperature, and Tylenol suppositories were administered when the resident could no longer swallow. The RN who assessed the resident the morning after the unwitnessed fall stated that the resident was no longer at baseline and had a rapid decline in neurological and respiratory status, and that she was not informed of the fall; she indicated she would have come in to assess for injuries and notified the hospice physician if she had known. The speech therapist acknowledged recommending 1:1 supervision for the resident due to fall risk but admitted she did not notify nursing of this recommendation, later stating she assumed everyone knew the resident was a fall risk. Collectively, these actions and omissions—failure to recognize and treat the resident’s position on the floor as a fall under facility policy, failure to perform required assessments and monitoring, and failure to notify the physician, hospice, and responsible parties—constituted the cited deficiency.
Failure to Assess and Monitor Anticoagulated Resident After Unwitnessed Fall
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for one cognitively impaired, fully dependent female resident who was on anticoagulant therapy. The resident had multiple diagnoses including hypertension, relapsing fever, type 2 diabetes, and vascular dementia, and was care planned as at risk for falls related to impaired mobility, psychotropic drug use, incontinence, impaired decision-making, and oxygen needs. She used a wheelchair, had a BIMS score of 0, and had a history of at least one fall since admission. Although she had an active order for Eliquis (apixaban) 2.5 mg twice daily, this anticoagulant therapy was not included in her care plan. On the date of the incident, the DON, who was working as a floor nurse, found the resident on the floor on a fall mat in her bedroom sometime between late afternoon hours. CNA A confirmed that the DON found the resident on the floor and requested assistance to move her from the floor back to bed. The DON stated she assessed the resident for pain but did not document this and did not complete a head-to-toe assessment, post-fall assessment, progress note, SBAR, incident report, neurological checks, or obtain vital signs. The DON did not notify the primary physician, hospice nurse, or responsible party. The DON and the Administrator both stated they did not consider the resident being found on the floor to be a fall because the resident was known to get out of bed and crawl onto the floor mat, despite the facility’s fall policy defining a fall as any event in which an individual unintentionally comes to rest on the floor, including when a resident is found on the floor without a witness. In the days following this unwitnessed fall, the resident exhibited pain and a decline in condition. LVN D reported administering Tramadol on two subsequent days because the resident was in pain, as indicated by facial grimacing per family guidance, and noted that the resident later remained in bed and was declining. The hospice wound care nurse subsequently ordered comfort care due to fluid-filled lungs and elevated temperature, and Tylenol suppositories were given when the resident could no longer swallow. Other staff, including LVN C and CNA B, described the resident as no longer at baseline, less responsive, and transitioning near end of life. RN A reported that the resident had been at baseline the morning before the fall but showed a rapid neurological and respiratory decline afterward. Interviews also revealed knowledge gaps among staff regarding anticoagulants, with the DON and Administrator unaware the resident was on a blood thinner and an LVN equating anticoagulants to aspirin, despite facility policy and hospice contract requirements to protect residents from accidents and to perform neuro checks and full assessments after unwitnessed falls. Record review confirmed there was no documentation of a head-to-toe assessment, pain assessment, post-fall assessment, progress note, SBAR, neurological checks, post-fall vital signs, or incident/accident report related to the unwitnessed fall. The incident was not reflected in the facility’s incidents and accidents log for that date. The facility’s fall policy required that any resident found on the floor without a witness be evaluated for possible injuries to the head, neck, spine, and extremities, not moved until evaluated by a nurse, and that vital signs and neuro checks be obtained and recorded for any unwitnessed fall. The hospice contract required the facility to make reasonable efforts to keep hospice patients protected from accidents and injury. Despite these requirements and the resident’s anticoagulant use and pain in the days following the event, the facility did not implement the required assessments, monitoring, documentation, or notifications after the unwitnessed fall, and the resident later expired at the facility.
Failure to Timely Report Alleged Abuse, Neglect, and Misappropriation to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report and investigate alleged abuse, neglect, and misappropriation to the State Survey Agency (SSA) as required by policy and regulation. For one cognitively impaired, fully dependent resident (CR #1) with a history of falls, hypertension, type 2 diabetes, vascular dementia, and oxygen needs, the DON found the resident on the floor on a fall mat in her room between 4:00 p.m. and 5:00 p.m. on 3/20/2026. Despite the resident being a known fall risk with care plan interventions for increased supervision and fall prevention, the DON did not complete a head‑to‑toe assessment, post‑fall assessment, progress note, SBAR, incident report, neurological checks, or vital signs after this unwitnessed fall. The DON also did not notify the physician, hospice nurse, responsible party, or administrator, stating she did not consider finding the resident on the floor to be an unwitnessed fall. A nurse later reported that when she saw the resident again on 3/23/2026, the resident was no longer at baseline and had a rapid decline in neurological and respiratory status, and the report notes that the neglect regarding lack of intervention and assessment after the fall was not reported to the SSA and that the resident subsequently died. The facility also failed to report an allegation of misappropriation involving a resident’s missing debit card. A resident with dementia, anxiety, cognitive decline, hemiplegia following CVA, and a history of falls, who used a wheelchair and required moderate assistance with ADLs, reported to the ADON that her debit card was missing and stated that her former roommate might have taken it. The ADON documented the report, notified the administrator and DON, and treated it as a grievance, but did not know the resolution. The administrator later stated that the debit card was never found, that she told the resident to cancel the card and obtain a new one, and that she did not report the incident to the SSA and did not know why. She acknowledged that no investigation was conducted because it was never reported, despite her role as Abuse Coordinator and the facility policy and Provider Letter PL 2024‑14 requiring reporting of misappropriation allegations. A third failure involved an allegation of sexual abuse that was not reported to the SSA. A resident with cognitive communication deficit, bipolar disorder, and other cognitive symptoms alleged that her roommate was sexually assaulting her by repeatedly entering the bathroom and watching her while she toileted. On one occasion, staff heard screaming, found both residents visibly upset in the hall, and documented that the resident alleged sexual assault by her roommate. The LVN documented that the resident reported the roommate came into the bathroom while she was toileting, that the roommate did not touch her, and that the resident declined a head‑to‑toe skin assessment. The resident called the police, reported a sexual assault, and the police questioned her and then left without making a report. Staff separated the residents and moved the complainant to another room. Subsequent interviews with the resident and social worker confirmed that the resident felt exposed and used the term sexual assault, describing feeling as if she had been “raped by her eyes,” and that the roommate had dementia and repeatedly opened the bathroom door. The administrator, who was hired after the incident, stated she did not know why the allegation was not reported, even though the facility’s abuse policy and PL 2024‑14 require reporting of abuse and suspicious incidents to the SSA within specified timeframes. The facility’s written Abuse, Neglect and Exploitation policy, revised 8/5/2025, requires the development and implementation of procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property, and mandates reporting of all alleged violations to the administrator, state agency, and other required agencies within specific timeframes. The policy defines misappropriation of resident property and includes mental and sexual abuse, and requires an Abuse Prevention Coordinator to report allegations or suspected abuse, neglect, or exploitation to the state survey agency. It specifies that allegations involving abuse or serious bodily injury must be reported immediately but not later than two hours, and all other allegations not involving abuse or serious bodily injury must be reported not later than 24 hours, with investigation results reported within five working days. Despite these written requirements, the facility did not report the neglect related to CR #1’s unwitnessed fall and subsequent decline and death, did not report the allegation of misappropriation of a resident’s debit card, and did not report the resident’s allegation of sexual assault by her roommate to the SSA.
Failure to Investigate and Protect Residents After Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and respond to alleged abuse, neglect, exploitation, and mistreatment for three residents, as required by its own policies and Provider Letter PL 2024-14. For one resident (CR #1), who was an elderly female with hypertension, relapsing fever, type 2 diabetes, vascular dementia, impaired mobility, incontinence, impaired decision-making, and on oxygen therapy, the DON found her on the floor on a fall mat in her bedroom between 4 p.m. and 5 p.m. on 3/20/2026. Despite the resident’s care plan identifying her as at risk for falls and the fall being unwitnessed, the DON did not complete a head-to-toe assessment, post-fall assessment, progress note, SBAR, incident report, neurological checks, or obtain vital signs. The DON also did not notify the primary physician, hospice nurse, responsible party, or administrator and did not initiate an investigation, stating she did not consider the event a fall and believed the resident had crawled out of bed. Record review showed that CR #1 was dependent on staff for all ADLs, used a wheelchair, and had a BIMS score of 00, indicating severe cognitive impairment. A nurse (RN A) reported that the resident was at her baseline when assessed on the morning of 3/20/2026, prior to the event, but by 3/23/2026 the resident was no longer at baseline and had a rapid decline in neurological and respiratory status. The administrator later acknowledged that the facility failed to notify the physician, family, ADON, and hospice company because the DON did not consider the event a fall, and confirmed that no investigation was conducted in connection with this unwitnessed fall, even though the resident subsequently died. For a second resident, an elderly female with dementia with anxiety, history of falls, age-related cognitive decline, ADHD, and left-sided hemiplegia/hemiparesis after CVA, the facility failed to investigate an allegation of misappropriation of property. The resident, who had a BIMS score of 8 (moderately impaired cognition) and used a wheelchair with moderate assistance for ADLs, reported on 3/24/2026 that her debit card was missing and suggested her former roommate might have taken it. The ADON documented that the resident and her friend reported the missing debit card and that she notified the administrator and DON for further follow-up. The ADON stated she spoke with the former roommate, who denied having the card, and that she reported the matter as a grievance to the administrator and DON but did not know the resolution. The administrator, who was also the Abuse Coordinator, stated the debit card was never found, that she told the resident to cancel the card and obtain another, and that she did not report or investigate the allegation because she did not think to investigate it, despite the facility’s policy defining misappropriation and requiring investigation of such allegations. For a third resident, an elderly female with cognitive communication deficit, bipolar disorder, and other cognitive symptoms, the facility failed to investigate an allegation of sexual abuse. Progress notes documented that in the early morning hours of 2/8/2026, staff heard screaming and found the resident and her roommate in the hall, both visibly upset. The resident stated that her roommate continued to open the bathroom door while she was toileting and alleged she was being sexually assaulted by the roommate. The LVN documented that the resident denied being touched and refused a head-to-toe skin assessment, and that the residents were separated and placed in different rooms. The resident called the police and reported sexual assault; the police officer spoke with her, was informed by staff that the roommate had severe dementia, and ultimately did not complete a police report. Subsequent interviews showed that Resident #3 described repeated incidents of her roommate following her into the bathroom, watching her while she used the toilet, and once pushing aside a wheelchair she had used to barricade the door, stating she felt violated and that the police told her the behavior was voyeurism. The social worker reported that the roommate, who had dementia and had previously had a private room, would open the bathroom door and stand looking at the resident while she was exposed, and that the resident said she felt like she was “raped by her eyes,” although the social worker was unaware of the reported reaching out to touch or barricading. The ADON stated she was informed that the resident’s roommate was watching her urinate and that the police came and left after assessing the situation, and that the nurses separated the residents. The administrator, who became employed after the incident, stated she did not know why the allegation of sexual assault was not investigated. Despite facility policy requiring immediate investigation of suspected abuse, neglect, exploitation, or misappropriation, including identification and interviewing of all involved persons and thorough documentation, there was no evidence of a formal investigation or comprehensive protective measures for any of these three residents’ allegations. The facility’s written Abuse, Neglect and Exploitation policy, revised 8/5/2025, required the development and implementation of procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property, and mandated immediate investigation of any suspicion or reports of such incidents. The policy specified that investigations must identify responsible staff, preserve evidence, interview alleged victims, alleged perpetrators, and witnesses, determine whether abuse, neglect, exploitation, or mistreatment occurred, and document the investigation completely. It also required protection of residents from physical and psychosocial harm during and after investigations, including immediate response to protect alleged victims, examinations for injury, increased supervision, room changes, emotional support, care plan revisions, and analysis of occurrences to prevent recurrence. In the cases of CR #1’s unwitnessed fall and subsequent decline, Resident #2’s missing debit card, and Resident #3’s allegation of sexual assault/voyeurism by a roommate with dementia, the facility did not follow these investigative and protective requirements as outlined in its own policy and referenced state guidance.
Overcooked Fried Fish Served Repeatedly to Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature, specifically related to fried fish served at a lunch meal. Resident #5, who was cognitively intact with diabetes and on a low concentrated sweets diet with regular texture and thin liquids, reported that the fried fish served on a Friday lunch was overcooked and inedible. During observation in the dining hall, Resident #5 had not consumed his meal tray and demonstrated the condition of the fish by tapping it on the dining room table multiple times, producing a sound that indicated how overcooked it was. He stated that the kitchen served fried fish every Friday and that it was always overcooked, and that although staff would prepare another piece if he complained, he believed it should be cooked correctly the first time. Resident #6, who was also cognitively intact, on a regular diet with thin liquids and no significant weight change or swallowing disorder, was observed in the dining hall during the same lunch meal with only half of the fried fish consumed. He stated that he had not finished the fish because it was overcooked and inedible and similarly reported that fried fish served every Friday was always overcooked. He also indicated that staff would prepare another piece of fish if he reported the problem, but he felt it should be prepared correctly initially. Resident #6 demonstrated the overcooked condition of the fish by picking up the half-eaten piece and tapping it on the dining room table multiple times, producing a sound to show how overcooked it was. Resident #7, cognitively intact and on a therapeutic diet including low concentrated sweets with regular texture and thinned fluids, was observed in his room eating lunch obtained from a restaurant while his facility meal tray was at the bedside. He stated that he declined the facility’s lunch tray because on Fridays the kitchen prepared fried fish that was always overcooked and inedible. Staff interviews corroborated that the fish served to these residents was not palatable. The cook who prepared the fish reported that he began frying the fish at 10:00 a.m., placed it on the steam table, and later found that the temperature had dropped; he then reheated the fish so it would be at the appropriate temperature and believed that some of the fish could have been overcooked as a result. These observations and statements show that the facility did not adhere to its policy requiring food and drinks to be palatable, attractive, and at a safe and appetizing temperature.
Failure to Update Care Plan to Reflect Therapeutic Diabetic Diet
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain a comprehensive, person-centered care plan that reflected a resident’s current therapeutic diet order. The resident, who was admitted with a primary diagnosis of diabetes mellitus due to an underlying condition with diabetic neuropathy, had a Quarterly MDS indicating a BIMS score of 14 (cognitively intact) and a trigger for a therapeutic diet. The resident’s care plan, categorized under Nutritional Status and edited in March 2026, documented that the resident was on a regular diet, did not eat pork products, and that family brought in outside food. The care plan’s long-term goal was to maintain stable weight, with approaches such as determining likes/dislikes, following diet as ordered, encouraging intake, monitoring meal percentages, and weighing per MD order, but it did not specify the ordered therapeutic diet. Record review showed a physician’s order for a low concentrated sweets diet with regular texture and thin liquids, which was not reflected in the resident’s care plan. Interviews with the ADON, CCM/MDS Coordinator, and Administrator confirmed that all residents were expected to have comprehensive person-centered care plans and that the resident in question had a low concentrated sweets therapeutic diet that was not updated in the care plan. Each interviewee acknowledged that the care plan did not reflect the current diet orders and that any clinical staff reviewing the care plan could have identified and corrected the discrepancy. The facility’s written policy required comprehensive, person-centered care plans with measurable objectives and timetables to meet residents’ needs, but this requirement was not met for this resident’s dietary needs.
Failure to Provide Scheduled Showers and Maintain Personal Hygiene for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living, specifically grooming and personal hygiene, to residents who were dependent on staff for showers and baths. For one resident, an older female with dementia, anxiety, hemiplegia following CVA, urinary tract infection, local skin infection, and a history of falls, the Quarterly MDS showed she was dependent for showers/baths, occasionally incontinent, and at risk for pressure ulcers. Her care plan directed staff to perform her baths on Tuesday, Thursday, and Saturday between 6 a.m. and 6 p.m., with no refusals of care planned. During observation, her hair appeared oily and stuck to her scalp, and she had thick white buildup on her bottom teeth. She stated she wanted a bath/shower because her hair was oily, did not remember when her last bath/shower was, and reported that a CNA had told her that morning she would receive a bath/shower, but by lunchtime she did not think it would occur. Her shower sheets could not be located on record review. A second resident, an older male with chronic kidney disease, muscle spasms, afib, congestive heart failure, hypertension, acute respiratory failure with hypoxia, MRSA, and lumbar spinal stenosis, had a Quarterly MDS indicating normal cognition, bilateral lower extremity impairment, dependence for showers/baths, an indwelling catheter, bowel incontinence, and risk for pressure ulcers. His care plan also specified scheduled baths/showers on Tuesday, Thursday, and Saturday from 6 a.m. to 6 p.m., with no refusals of care planned. He reported that he only received a shower/bath once a week, wanted more frequent bathing, and had been told there was not enough staff. Record review showed his last documented shower sheet was dated several weeks earlier, and he later stated he had not yet had a shower/bath that week and believed his last one was on a specific date in the prior week. Staff interviews revealed systemic issues contributing to missed showers/baths. CNAs reported that hall closures for renovations led to resident relocations and changes in shower schedules, with certain halls assigned specific shower days and no showers given on night shift. Multiple CNAs stated there were only two CNAs on the 6 a.m. to 6 p.m. shift instead of the expected three to four, that they were responsible for showers/baths in addition to feeding, changing, and monitoring fall-risk residents, and that there was not enough time to complete all showers/baths. One CNA noted a designated shower CNA worked only on certain days, leaving regular CNAs to manage showers on other days, and acknowledged that some residents did not receive their scheduled baths/showers. The administrator and ADON stated the facility was supposed to have 3–4 CNAs so one could function as a shower technician and that nurses and the DON were to oversee showers via shower sheets, while an LVN reported that a resident frequently refused showers and that refusals were to be documented and addressed. However, staffing shortages, lack of night-shift participation in bathing, and missing or outdated shower documentation demonstrated that scheduled showers were not consistently provided as required by residents’ care plans and facility policies on showers and bed baths.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to post the required daily nurse staffing information on at least one day. On the morning of 02/10/26 at 10:39 AM, observation showed that the designated nurse staffing posting area on the wall facing the lobby, across from the nursing station, was empty and did not display the required staffing information. The facility’s written policy, implemented in 03/2025, required that a Nurse Staffing Sheet be posted on a daily basis at the beginning of each shift, include the facility name, current date, current resident census, and the total number and actual hours worked by RNs, LPNs/LVNs, and CNAs per shift, and be placed in a prominent, readily accessible location. In interviews, the DON stated she was responsible for updating the staffing posting, that it was typically updated at the beginning of the shift, and that on 02/10/26 it was not updated timely because she was in a morning meeting. The Administrator, who had just started working at the facility on 02/09/26, stated that the DON and ADON were responsible for the posting and that it should be posted as early as the start of the first shift at 6:00 AM; he was not aware it had not been posted timely on 02/10/26. The ADON confirmed that she shared responsibility for the posting, that it should be updated daily at the start of her shift, and reported that on 02/10/26 she arrived at 9:00 AM and was busy with patient-related situations, which delayed updating the posting. Both the DON and ADON acknowledged that failure to update the posting could leave visitors without current information on census and staffing.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or observed events are provided in the report.
Failure to Conduct Proper Assessment After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not conduct a head-to-toe assessment to determine if a resident had sustained any injuries from an apparent fall. The resident, a male with severe cognitive impairment and multiple diagnoses including dementia and diabetes, was found on the floor in his room. Despite the facility's policy requiring a thorough assessment before moving a resident after a fall, the Licensed Vocational Nurse (LVN) involved did not perform the necessary assessment, citing pressure from the resident's family as a reason for her oversight. Interviews with the LVN, a Certified Nursing Assistant (CNA), the Director of Nursing (DON), and the Administrator confirmed that a head-to-toe assessment should have been conducted to rule out any serious injuries before moving the resident. The facility's fall prevention policy also mandates such an assessment, including checking vital signs and range of motion, to ensure the resident's safety. The failure to perform this assessment could place residents at risk of not receiving necessary care and services to address their individual needs.
Improper Lifting Technique Used for Resident
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to a deficiency in accident prevention. A male resident with severe cognitive impairment and multiple health conditions, including dementia and muscle weakness, was involved in an incident where he was improperly lifted off the floor by staff. The resident's care plan included measures to prevent falls, such as keeping the bed in its lowest position and using a fall mat. However, when the resident was found on the floor, staff members lifted him by his arms instead of using a mechanical lift, which is the correct procedure to prevent injury. Interviews with staff members, including LVNs and CNAs, revealed inconsistencies in their accounts of how the resident was lifted. While one CNA claimed they used a cradle position, video evidence showed the resident was lifted by his arms. Other staff members confirmed that the proper procedure involves using a mechanical lift to avoid potential dislocations. The Director of Nursing also stated that a mechanical lift should be used after assessing the resident, and lifting by extremities is not appropriate. This failure to follow proper lifting techniques could place residents at risk of accidents and injuries.
Failure to Provide Scheduled Showers and Grooming
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination by not providing scheduled showers and grooming for four out of six residents reviewed. Resident #1, a male with severe cognitive impairment, heart disease, and reduced mobility, did not receive his scheduled showers and grooming, resulting in an overgrown beard and unshaven appearance. Resident #2, a female with moderate cognitive impairment and multiple health issues, missed her scheduled shower, leaving her feeling unclean and uncomfortable. Resident #3, a male with kidney failure and hypertension, did not have a care plan addressing his bathing needs and missed his scheduled shower. Resident #4, a male with multiple sclerosis and major depressive disorder, also missed his scheduled showers, leading to an unkempt appearance. Interviews with residents and staff revealed that staffing shortages and the elimination of a dedicated shower technician contributed to the failure to provide these essential services. The facility's policies on resident rights and activities of daily living emphasize the importance of treating residents with dignity and providing necessary care to maintain their hygiene and grooming. However, the lack of a specific shower policy and inadequate staffing led to the neglect of these responsibilities, impacting the residents' dignity and quality of life.
Failure to Provide Scheduled Showers and Grooming Services
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary services to maintain their hygiene and grooming. This deficiency was observed in four residents who did not receive scheduled showers and grooming services. Resident #1, a male with severe cognitive impairment, was not provided with scheduled showers and personal grooming, resulting in an overgrown beard and nasal hairs. Despite his care plan specifying shower days and times, the last documented shower was not consistent with the schedule. Resident #2, a female with moderate cognitive impairment and requiring extensive assistance for bathing, did not receive her scheduled showers. She expressed feeling unclean and noted that the facility had previously employed a dedicated shower technician, a position that was recently eliminated. Resident #3, a male with ongoing health issues, did not have a care plan addressing his bathing needs and did not receive a shower on a scheduled day. Resident #4, a male with multiple sclerosis and major depressive disorder, also did not receive his scheduled showers and was observed with an overgrown beard. Interviews with staff, including CNAs and the ADON, revealed inconsistencies in the provision of showers and grooming, attributed to staffing challenges and the recent elimination of the shower technician position. The facility's policies on resident rights and ADLs emphasize the importance of maintaining residents' dignity and providing necessary care, which were not adhered to in these cases. The failure to provide scheduled showers and grooming services was acknowledged by the facility's administration as a dignity and rights issue.
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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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