Alameda Oaks Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Corpus Christi, Texas.
- Location
- 1101 S Alameda, Corpus Christi, Texas 78404
- CMS Provider Number
- 455687
- Inspections on file
- 37
- Latest survey
- April 4, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Alameda Oaks Nursing Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse reporting policy when a male resident with dementia and a history of traumatic brain injury struck another cognitively impaired, post-stroke resident twice in the eye in the dining room. Staff redirected the aggressor and notified the RP, MD, and DON, and the incident was reported to local law enforcement, but it was not reported to the State Survey Agency within the required 2-hour timeframe for alleged abuse. Record review showed no prior aggressive behavior by the aggressor and confirmed the victim had severe cognitive and communication deficits. The facility’s written policy required immediate, but no later than 2-hour, reporting of alleged abuse or serious bodily injury to the administrator and external officials, including the State Survey Agency.
A resident with respiratory failure, tracheostomy, dependence on supplemental O2, hemiplegia, and a persistent vegetative state, who required maximum assistance with all ADLs and could not be reliably understood, was observed in bed without a call light within reach; the device was clipped behind the resident on the wall. The resident’s care plan called for a specialized call device that was easier to operate, and facility policy required call lights to be accessible to residents in bed, with nursing to determine an alternative if the resident could not use the standard system. An LVN and CNA who had recently repositioned the resident acknowledged the expectation that call lights be within reach for all residents but could not explain why it was not, and the DON confirmed the same expectation.
A resident admitted with type 2 diabetes mellitus and other chronic conditions did not have diabetes addressed in their baseline care plan due to an admitting nurse's oversight in the electronic assessment. This omission resulted in the absence of diabetes-related interventions in the initial care plan, despite the resident's diagnosis and need for glucose monitoring and oral antidiabetic medication. The error was not detected during subsequent reviews by nursing staff and the MDS Coordinator.
A resident with COPD and Alzheimer's Disease received oxygen therapy on multiple occasions, but staff failed to document these administrations in the MAR as required by facility policy. Interviews and other records confirmed the resident's use of oxygen, but the MAR did not reflect this, resulting in incomplete clinical records.
A resident with severe cognitive impairment and multiple diagnoses did not have care plan meetings held with her or her representative for several months, despite facility policy and staff acknowledgment that such meetings should occur at least quarterly. Documentation showed the last meeting attended by the representative was in March, with no evidence of further involvement or notification.
A resident with COPD and Alzheimer's experienced a significant decline, including low oxygen saturation and decreased consciousness. Although the physician was notified promptly, the resident's representative was not informed until a week later, contrary to facility policy requiring immediate notification after such changes.
Three residents did not receive pharmaceutical services in accordance with physician orders and facility policy: one resident received Morphine late due to an LVN's unfamiliarity with scheduled narcotics, another received Tramadol late because of staffing issues, and a third was given Tramadol without a current physician order after a hospital stay. The DON confirmed these actions did not follow policy requiring timely and authorized medication administration.
Staff failed to document the administration of controlled pain medications on the MAR for three residents, despite administering the medications and signing the narcotic sheet. The involved residents had complex medical conditions requiring pain management, and staff interviews confirmed that the omission was due to being busy or distracted, even though they were aware of and trained on the facility's documentation policy. The DON verified that the required documentation was missing from the MARs.
Surveyors found that food storage, preparation, and equipment sanitation practices were not in accordance with professional standards. Dinnerware and cooking utensils were not properly cleaned or maintained, with visible residues and damage. Food items in the refrigerator and freezer were not labeled, dated, or sealed correctly, and some were expired. The walk-in freezer had significant ice accumulation and boxes stacked to the ceiling. The dietary manager was unaware of several food safety requirements, and sanitation of equipment such as steam table wells was inadequate.
A nurse left a medication cart laptop screen open and a report sheet with multiple residents' information exposed, making confidential records accessible to unauthorized individuals. Interviews confirmed staff awareness that this was a HIPAA violation and contrary to facility policy requiring the protection of resident information.
A resident with right-sided hemiplegia, aphasia, and dementia was found with their call light out of reach, despite a care plan intervention requiring it to be accessible. Staff interviews confirmed the call light should have been within reach, and the resident was unable to communicate verbally or by other means. Facility policy required a comprehensive care plan to meet such needs, but this was not fully implemented.
A resident with multiple complex medical conditions and chronic pain did not have accurate documentation of narcotic administration, as the MAR did not match the narcotic sheet for a prescribed pain medication. Staff interviews confirmed that both records are required to be consistent, but the facility failed to ensure this, resulting in incomplete and inaccurate medical records.
A resident with a surgical wound and impaired cognition did not receive proper infection control during wound and incontinent care. The ADON did not follow correct wound cleansing technique or ensure all wounds were treated, and a CNA failed to perform hand hygiene and used dirty gloves while assisting with wound care. The resident's room lacked required EBP signage and PPE, and physician orders were unclear regarding wound care for all incision sites.
The facility did not provide or document written transfer or discharge notifications to residents, their representatives, or the local ombudsman as required. Interviews confirmed that these notifications were not sent, and a review of discharges showed this process was not followed for multiple residents.
A resident with an indwelling Foley catheter was observed with an uncovered drainage bag, leaving urine visible to staff and visitors. Staff interviews revealed confusion about responsibility for placing privacy bags, and the facility's policy required catheter bags to be covered to maintain resident dignity. No recent in-service training on this issue was documented.
A resident with cognitive awareness and physical care needs reported to an LVN that another LVN had physically abused her by throwing her into a wheelchair. The allegation, though reported months after the alleged incident, was not communicated to local law enforcement as required by facility policy and federal regulations. The administrator did not notify law enforcement due to the time elapsed, resulting in a failure to meet mandated reporting requirements.
A resident with a history of impaired mobility and cognition experienced an unwitnessed fall in a facility. Two CNAs found the resident on the floor, assisted her into a wheelchair, and then into bed without notifying a nurse or conducting an evaluation for injuries. The resident later reported leg pain, leading to an X-ray that revealed fractures. The facility's policy required a nurse evaluation before moving a resident after a fall, which was not followed, resulting in delayed medical intervention.
A resident with severe cognitive impairment exited a facility unsupervised due to a new receptionist's failure to properly set the door alarm. The resident, at risk for elopement, was found sitting outside the front door for 3-5 minutes before being redirected inside by a staff member. The incident highlights inadequate supervision and improper door security.
The facility failed to maintain proper sanitation and food safety standards in its kitchen, with issues such as a dirty ice machine, unclean drinking glasses, eroded non-stick pans, and pest control problems. The Assistant DM was unaware of these issues and failed to report them, and the facility's policies on infection control and cleaning were not adequately followed.
The facility failed to maintain essential kitchen equipment, including a walk-in freezer with significant ice build-up and a drooping ceiling, insufficient lighting in the walk-in freezer and refrigerator, and non-functional vent hood lights and exhaust fan. Staff interviews revealed a lack of communication and awareness of these issues, with minimal maintenance records and no invoices for necessary repairs.
The facility failed to follow physician orders for regular weight monitoring for eight residents, leading to potential risks of severe weight loss or gain. The deficiency was due to a lack of systematic monitoring and documentation, as revealed through interviews and record reviews. Staff acknowledged the oversight, which was only addressed in a QAPI meeting after the issue was identified.
The facility failed to maintain effective pest control in the kitchen, with ants found on a prep table and rodent droppings on the floor. Staff interviews revealed a lack of awareness and responsibility for pest control measures, and the facility's pest control logs and policies were not provided. The ADM acknowledged the need for kitchen repairs but was unaware of the extent of the issues.
A resident with Parkinson's disease and other conditions was unable to use the call light due to physical limitations, leading to a deficiency in accommodating her needs. Despite the facility's policy requiring accessible call lights, the resident's inability to use it was not addressed, and there was no specific assessment for call light use. Staff sometimes heard her calling out for help, but assistance during rounds could result in delays.
A resident's request to keep her bedroom door closed for privacy was not honored by the facility staff, despite being documented in her care plan. The resident, who is cognitively intact and has a history of dementia and other conditions, expressed frustration over the noise from the hallway. The DON acknowledged the importance of respecting residents' preferences to prevent emotional distress.
A facility failed to change a resident's oxygen tubing weekly as ordered, posing an infection risk. The resident, with Alzheimer's and Heart Failure, had tubing labeled from weeks prior, despite orders to change it every Sunday night. Staff interviews confirmed the tubing should be changed weekly, and the facility's policy supported this practice.
A medication/treatment cart was found unlocked at the nurse's station, accessible to residents. LVN B left the cart unlocked while attending to a resident emergency, and LVN F confirmed forgetting to lock it. Both acknowledged the importance of keeping carts locked, as per facility policy. The DON reiterated that carts should be locked when unattended.
Failure to Timely Report Resident-on-Resident Physical Abuse Allegation to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving the reasonable suspicion of a crime were reported to the State Survey Agency within required time frames. On 02/05/2026 at approximately 12:52 PM, a nurse’s note documented that a male resident with dementia, a history of traumatic brain injury, and moderate cognitive impairment (Resident #2) was witnessed in the dining room hitting another male resident (Resident #3) twice in the left eye. Staff redirected Resident #2, who then left the dining room and went to his room. The note indicated that the responsible party, physician, and DON were notified. The facility’s abuse and neglect policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property be reported immediately, but not later than 2 hours after the allegation if it involved abuse or resulted in serious bodily injury, to the administrator and other officials including the State Survey Agency. Resident #2’s record showed he had dementia with agitation, irritability, and poor impulse control, and his care plan, initiated on 02/05/2026, identified an episode of physical aggression toward another male resident related to these conditions. Interventions included analyzing triggers and de-escalation strategies, assessing for sensory deficits, documenting behaviors and interventions, ordering an emergency detention warrant for psychiatric evaluation, medication adjustment, and monitoring for danger to self or others. Prior to this incident, the administrator reported that Resident #2 had not displayed aggression toward other residents and there was no indication of prior aggressive behavior in the record review. Resident #3’s record indicated severe cognitive impairment following a stroke, with hemiplegia/hemiparesis affecting the right dominant side and aphasia, and his care plan focused on impaired cognition and communication strategies. Surveyors’ review of incident and accident reports from 01/03/2026 to 04/03/2026 identified one incident on 02/05/2026 involving Resident #2, with no other concerns noted. During interview, the current administrator, who had been in the role for about one week, stated that the 02/05/2026 incident required notification to local law enforcement and to the State Survey Agency. She confirmed that law enforcement was notified, but the State Survey Agency was not notified within the required 2-hour time frame, and she did not know why the previous administrator failed to complete this notification. The administrator reported that Resident #3 did not sustain any skin irregularity or discoloration and did not verbalize fear of living at the facility. The facility’s written policy, last reviewed on 11/24/2025, reiterated the requirement to report such allegations within 2 hours if they involve abuse or result in serious bodily injury, or within 24 hours if they do not, to the administrator and appropriate external officials, including the State Survey Agency and adult protective services in accordance with state law.
Failure to Ensure Call Light Accessibility for Non-Communicative 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 the resident’s care plan. The resident was an adult female with acute and chronic respiratory failure with hypoxia, tracheostomy, dependence on supplemental oxygen, hemiplegia and hemiparesis following cerebral infarction, and a diagnosis of persistent vegetative state. A quarterly MDS indicated she was rarely or never understood, unable to answer cognitive questions, and required maximum assistance with all ADLs, with mobility not assessed due to her vegetative state. Her care plan identified an inability to communicate with others related to the persistent vegetative state and included an intervention for a specialized call device that was easier to operate. During observation, the resident was found in her room with no call light within reach; the call light was clipped to itself behind her on the wall. Staff interviews confirmed that the LVN and CNA who had repositioned the resident were unaware or unsure why the call light was not placed within reach, despite acknowledging that call lights were expected to be within reach of all residents, including this resident. The DON also stated that all residents, including this resident, were expected to have a call light pinned on the bed, blanket, or within reach, and referenced the resident’s potential to go into respiratory distress. Facility policy on the resident call system required that the call light be positioned within reach of the resident and accessible while in bed or other sleeping accommodations, and that if a resident could not use the call light, the nurse must determine an adequate alternative.
Failure to Include Diabetes Mellitus in Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to develop a baseline care plan that included necessary instructions for effective and person-centered care for a newly admitted resident with multiple diagnoses, including type 2 diabetes mellitus with diabetic chronic kidney disease and heart disease. Upon admission, the resident's baseline care plan assessment did not indicate the presence of diabetes mellitus, as the corresponding box was not checked by the admitting nurse. As a result, the baseline care plan did not include interventions or care planning for diabetes management, despite the resident's documented diagnosis and need for oral antidiabetic medication and glucose monitoring. Interviews with facility staff revealed that the admitting nurse was aware of the resident's diabetes diagnosis but inadvertently failed to select the appropriate option in the electronic assessment, which led to the omission of diabetes-related care planning. The process for developing baseline care plans involved the admitting nurse completing the assessment, followed by review and sign-off by an RN, and a final review by the MDS Coordinator. However, the error was not identified during these reviews, resulting in the resident's baseline care plan lacking critical information regarding diabetes care. The deficiency was identified through record review and staff interviews, which confirmed that the baseline care plan did not reflect the resident's admitting diagnosis of diabetes mellitus. The facility's policy required completion and implementation of a baseline care plan within 48 hours of admission to promote continuity of care and resident safety, but this was not achieved in this instance due to the oversight during the admission process.
Failure to Accurately Document Oxygen Administration in MAR
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with diagnoses of COPD and Alzheimer's Disease. Specifically, the Medication Administration Record (MAR) did not reflect the administration of oxygen therapy on nine occasions during August, despite other documentation and staff interviews confirming that the resident received oxygen via nasal cannula on those dates. The resident had an active physician order for oxygen at 2 liters/minute as needed for shortness of breath, which was not properly documented in the MAR. Interviews with the ADON and DON confirmed that the resident intermittently used oxygen, particularly after an episode of shortness of breath, and that it was the responsibility of nursing staff to document all medication and treatment administration in the MAR. Facility policy also required documentation of all administered medications and treatments. The lack of accurate documentation in the MAR resulted in incomplete clinical records for the resident.
Failure to Involve Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and her representative were involved in the development and implementation of her person-centered care plan. Record review showed that the resident, an elderly female with diagnoses including COPD and Alzheimer's Disease and a severely impaired BIMS score, had a care plan developed with interventions updated throughout her stay. However, documentation revealed that the last care plan meeting attended by the resident's representative was in early March, and there was no evidence of subsequent meetings or notifications to the representative after that date. Interviews with facility staff confirmed that no care plan meetings had been held with the resident or her representative since the new social worker began employment in mid-July. The social worker and administrator both acknowledged the importance of involving the resident and representative in care planning and stated that meetings should occur at least quarterly. Facility policy also required advance notice and participation of the resident and representative in care planning conferences. Despite these requirements, the facility did not provide evidence of such involvement for the resident after the March meeting.
Failure to Immediately Notify Resident Representative After Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's representative (RP) following a significant change in the resident's condition. The resident, an elderly female with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Alzheimer's Disease, experienced a sudden decline on the morning of 08/14/25, including abnormal vital signs, decreased intake, functional decline, decreased level of consciousness, low-grade fever, shortness of breath, non-productive cough, abnormal lung sounds, and cold symptoms. Her oxygen saturation was measured at 82%, and she was administered oxygen via nasal cannula as per physician orders. The change in condition evaluation was completed by the ADON, who documented that the physician was notified on the same day. However, the RP was not notified of the resident's change in condition until a week later, as indicated in the documentation and confirmed by interviews with the RP, ADON, and DON. The RP only learned of the incident after requesting medical records following the resident's discharge. The facility's policy requires immediate notification of the resident, physician, and representative in the event of a significant change in condition, but this protocol was not followed in this instance.
Failure to Provide Timely and Authorized Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for three residents. In the first instance, a resident with chronic pain and multiple comorbidities, including peripheral vascular disease and hemiplegia, did not receive his scheduled dose of Morphine at the prescribed time. The medication, ordered to be administered twice daily at 9:00 am and 5:00 pm, was instead given at 7:57 pm by an LVN who was unaware of the scheduled time and cited being busy and unfamiliar with the number of scheduled narcotics. The LVN acknowledged not following facility policy, which requires medications to be administered within a one-hour window of the scheduled time. A second resident, who had severe cognitive impairment and multiple diagnoses including vascular dementia and hemiplegia, also did not receive her scheduled dose of Tramadol at the prescribed time. The medication, ordered for administration twice daily at 9:00 am and 5:00 pm, was given at 8:00 pm. The responsible LVN was not available for interview, but the DON confirmed the medication was administered late due to staffing issues, specifically the absence of a medication aide, and that the LVN was responsible for the delay. The facility policy, as stated by the DON, requires timely administration of medications within a one-hour window. In a third case, another resident with a history of heart failure, chronic kidney disease, and diabetes received Tramadol without a current physician order. The LVN administered the medication after the resident requested it, mistakenly believing the order was still active following a recent hospital stay. The LVN did not review the resident's chart prior to administration and did not contact the physician to confirm or obtain a new order. The DON confirmed that the medication was given without an order and that this was not in accordance with facility policy, which prohibits administering medications without a valid physician order.
Failure to Document Narcotic Administration on MARs
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for three residents by not documenting the administration of controlled pain medications on the Medication Administration Record (MAR) as required by facility policy and professional standards. For each resident, staff administered medications such as tramadol and morphine, signed the narcotic sheet, but did not record the administration on the MAR. Interviews with the involved LVNs and SDC confirmed that they were responsible for this documentation and acknowledged the omission, often attributing it to being busy or distracted after signing the narcotic sheet. The residents involved had significant medical histories, including chronic pain, peripheral vascular disease, hemiplegia, heart failure, chronic kidney disease, diabetes, and vascular dementia. Despite having care plans and physician orders for pain management, the staff did not consistently document the administration of as-needed pain medications on the MAR, even though they had been trained on the importance of this process and the facility's policy required documentation in both the narcotic sheet and the MAR. The Director of Nursing (DON) confirmed that the staff did not follow facility policy, which mandates that all administered narcotics be documented in two places. The DON also verified that the MARs for the relevant dates were blank, indicating the medications were not recorded as given. Staff interviews revealed an understanding of the importance of proper documentation for resident safety and continuity of care, but the required documentation was still not completed at the time of the incidents.
Deficient Food Storage, Preparation, and Equipment Sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the kitchen and nutrition room. Observations revealed that dinnerware, including clear plastic drinking glasses and plastic plate covers, were not properly cleaned or dried, with a thick removable whitish substance present and glasses left wet on racks without drainage mats. Additionally, cooking equipment such as non-stick pans and large cooking pots were found to be in poor condition, with flaking coatings, dents, pitting, and dark discoloration. Utensils in the clean bin were dirty, damaged, or chipped, and some were deemed unsafe for use by the dietary manager (DM). Food storage practices were also deficient. Items in the refrigerator and freezer, such as trays of beverages and pitchers, were not labeled or dated, and some food items, including apple juice containers, were found to be expired. Opened boxes and bags of frozen foods were not tightly sealed, and there was a significant accumulation of ice in the walk-in freezer, with boxes stacked to the ceiling. The DM was unaware of several food safety requirements, including the need for labeling, dating, and proper sealing of food items, and acknowledged that expired and improperly stored food could pose a risk to residents. Sanitation of equipment was inadequate, as evidenced by the presence of a flaking, yellow/white substance in all steam table wells. The DM was unable to confirm how often these wells were cleaned. The facility's policies and training records indicated requirements for proper food handling, storage, and equipment maintenance, but these were not consistently followed. The DM admitted responsibility for the kitchen and acknowledged lapses in staff training and oversight. The registered dietician was not available for interview, and ongoing issues with the walk-in freezer were documented in repair records.
Failure to Protect Resident Privacy and Confidentiality of Medical Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records for 7 out of 10 residents reviewed. During observations, a nurse (LVN-D) left a medication cart laptop screen open and unattended, displaying multiple residents' information. Additionally, a report sheet containing multiple residents' information was left face up on the medication cart, accessible to anyone passing by. These incidents were directly observed by surveyors, who noted that the information was visible and could have been accessed by unauthorized individuals. Interviews with the involved nurse, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) confirmed that leaving residents' information exposed is considered a HIPAA violation. The nurse acknowledged awareness of the requirement to lock the computer screen and secure paperwork but stated she was busy and forgot to do so. Facility policy and residents' rights documents reviewed by surveyors also confirmed the expectation that personal and clinical records be kept confidential and not released without consent.
Failure to Ensure Call Light Accessibility for Nonverbal Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, including right-sided hemiplegia, aphasia, and dementia. The resident's care plan identified the need for the call light to be within reach as an intervention to reduce fall risk, but during an observation, the call light was found coiled on the floor approximately three feet from the resident's bed, out of the resident's reach. The resident, who was unable to speak and had limited ability to communicate, could only respond to questions with head movements and was unable to indicate how long the call light had been inaccessible. Interviews with staff confirmed that the call light should have been clipped to the bed within the resident's reach, and both a CNA and an LVN acknowledged the importance of call light accessibility, especially for this resident who could not verbally call for help. The Director of Nursing also stated that lack of access to the call light could result in delayed staff response to resident needs. Review of facility policy confirmed the requirement for a comprehensive care plan with measurable objectives and timeframes to meet residents' needs, which was not fully implemented in this case.
Failure to Accurately Document Narcotic Administration in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically regarding the administration of hydrocodone-acetaminophen for pain management. Record review revealed that the Medication Administration Record (MAR) did not match the narcotic sheet, which documented the removal and administration of the medication. The narcotic sheet and blister pack both indicated that a dose was given, but the MAR lacked documentation for the corresponding date and time. Interviews with facility staff, including the Administrator, ADON, and DON, confirmed that both the MAR and narcotic sheet are required to be consistent and accurately reflect when a narcotic is dispensed to ensure proper medication tracking and resident safety. The resident involved had multiple complex medical conditions, including diabetes, necrotizing fasciitis, stage 4 and unstageable pressure ulcers, and was receiving insulin and IV medications. The resident's care plan included chronic pain management with analgesic medications as ordered by the physician. Despite these needs, the facility did not ensure that the MAR was updated to reflect the actual administration times of the prescribed pain medication, as evidenced by the discrepancy on the narcotic sheet and MAR. Facility policy requires accurate documentation and investigation of any discrepancies, but this was not followed in this instance.
Failure to Maintain Infection Control Practices During Wound and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident with a surgical wound. Specifically, the Assistant Director of Nursing (ADON), who also served as the Infection Control Preventionist (ICP), did not demonstrate proper wound cleansing technique and did not ensure all surgical wounds were addressed during wound care. Physician orders for wound care were unclear and did not specify care for all four surgical incision areas, resulting in one wound not being treated during the observed wound care session. Additionally, the resident's room lacked Enhanced Barrier Precautions (EBP) signage and appropriate personal protective equipment (PPE) supplies, despite facility policy requiring EBP for residents with wounds. During observed care, a Certified Nursing Assistant (CNA) failed to perform hand hygiene between providing incontinent care and applying a clean brief, and then assisted with wound care without changing gloves or sanitizing hands. The CNA placed a dirty, gloved hand over an uncovered surgical wound throughout the wound care process. Both the ADON and CNA acknowledged these lapses in infection control during interviews, and the ADON confirmed that the resident should have been on EBP precautions but was overlooked. The resident involved had a history of a right hip fracture with surgical intervention, type 2 diabetes, and severely impaired cognition.
Failure to Provide Required Written Transfer and Discharge Notifications
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for resident representatives to ensure safe and orderly transfers or discharges. Specifically, the facility did not send written transfer or discharge notifications to residents, their representatives, or the local ombudsman in a language and manner they could understand. Interviews with the administrator and the ombudsman confirmed that these notifications were not being sent, and the administrator was unaware of the reason for this lapse. The facility's own policy required such notifications and documentation, but these steps were not followed. A review of the facility's discharge report over a three-month period showed 55 discharges to various settings, including acute care hospitals, funeral homes, hospice, other nursing homes, and private homes, both with and without home health services. The facility's policy also required that the reasons for transfer or discharge be recorded in the resident's medical record, but the report indicates that the required written notifications were not provided as stipulated.
Failure to Ensure Foley Catheter Privacy Bag Use for Resident Dignity
Penalty
Summary
A deficiency occurred when a male resident with a history of benign prostatic hyperplasia, bilateral hydronephrosis, and urinary retention was observed with an indwelling Foley catheter drainage bag that was not covered by a privacy bag. The urine in the catheter bag was visible to staff and visitors passing by the resident's room on two separate occasions. The resident's care plan included interventions for catheter care but did not specify the use of privacy bags, and the physician's orders addressed catheter maintenance but not privacy coverings. Interviews with staff revealed confusion regarding responsibility for placing privacy bags, with a CNA stating that only nurses could place them, while an LVN clarified that all clinical staff were permitted to do so. Both staff members and the DON acknowledged that privacy bags are intended to protect resident dignity by concealing urine output. The facility's dignity policy also specified that urinary catheter bags should not be left uncovered. There was no documentation of recent in-service training on this topic, and requested records of such training were not provided by the time of the exit conference.
Failure to Timely Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported to local law enforcement within the required timeframe. Specifically, a resident with Parkinson's disease and dysphagia, who was cognitively intact and required assistance with activities of daily living, informed an LVN that another LVN had allegedly thrown her into a wheelchair. This allegation was reported to facility staff on 11/24/2024, but the incident was said to have occurred several months prior, in June 2024. Despite the facility's policy requiring notification of law enforcement for alleged abuse, the administrator did not contact local law enforcement due to the time elapsed since the alleged event. The administrator enacted the facility's abuse protocol by removing the alleged perpetrator from duty and notifying state agencies, but did not notify law enforcement as required. The facility's policy and federal regulations mandate immediate reporting to law enforcement for allegations of abuse, regardless of when the incident is reported. The failure to notify law enforcement was based on the administrator's decision that the time elapsed since the alleged incident did not warrant such notification, despite the policy's requirements.
Failure to Evaluate Resident After Fall Leads to Fractures
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following an unwitnessed fall. The incident involved a resident with a history of impaired mobility, weakness, impaired cognition, and pain, who was at risk for falls. On the morning of the incident, the resident was found on the floor by two CNAs after calling for help. The CNAs assisted the resident into a wheelchair and then into bed without notifying a nurse or conducting a proper evaluation for injuries. The resident later reported pain in her leg to another CNA, who then informed a nurse. An X-ray was ordered, revealing fractures in the resident's left distal femoral shaft and right tibia and fibula. The resident was subsequently transferred to a hospital, where it was determined that the left femur fracture was not fixable, leading to a recommendation for a left above-knee amputation. Interviews with the resident and staff revealed inconsistencies in the accounts of the incident, with the resident recalling a fall and subsequent pain, while the CNAs initially did not report the fall. The facility's policy required a licensed nurse to evaluate a resident before moving them after a fall, which was not followed in this case. The CNAs involved were terminated following an investigation, and the facility took corrective actions to address the deficiency. However, the initial failure to adhere to the policy and properly assess the resident's condition after the fall led to a delay in appropriate medical intervention.
Resident Exits Facility Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, leading to the resident exiting the facility through the front door. The resident, a male with severe cognitive impairment, was at risk for elopement due to confusion, disorientation, and impaired safety awareness. Despite these risks, the resident was able to leave the facility unsupervised and was found sitting on a bench outside the front door. The incident occurred when a new receptionist, who was not properly trained on setting the door alarm, went on break and locked the door incorrectly. This allowed the resident to exit the facility without supervision. The resident was outside for approximately 3-5 minutes before being noticed by a Central Supply staff member, who then redirected him back inside without incident. Interviews with staff revealed that the resident was not displaying exit-seeking behavior and was simply sitting outside enjoying the fresh air. However, the lack of proper supervision and failure to secure the facility's entrance led to the resident being outside unsupervised, which could have posed a risk for injury or accidents.
Facility Fails to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen, as observed during a survey. The ice machine was found to have a reddish substance along the ice chute, and drinking glasses were coated with a whitish yellow substance, indicating inadequate cleaning. Non-stick pans were eroded, and pots and pans were dented, which could harbor bacteria. Additionally, ants were observed on a prep table, and there was a significant ice build-up in the walk-in freezer, causing structural concerns. Personal items were improperly stored in food preparation areas, and the lighting in the walk-in refrigerator and freezer was insufficient. Interviews with the Assistant Dietary Manager (DM) revealed a lack of awareness and action regarding these issues. The Assistant DM admitted to not knowing the cause of the substances on the ice chute and glasses and acknowledged the potential health risks to residents. She also mentioned that the kitchen staff followed a daily cleaning schedule, but there were gaps in the cleaning log, and she was unaware of the extent of the ice build-up in the freezer. The Assistant DM also failed to report issues with lighting and pest control, assuming others were already aware. The facility's policies on infection control and cleaning were not adequately followed, as evidenced by the lack of ongoing training and incomplete cleaning logs. The facility's policy required regular training and monitoring of food storage, preparation, and service areas, but these were not effectively implemented. The absence of a section for the ice machine in the cleaning log and the lack of significant training on infection control contributed to the deficiencies observed during the survey.
Facility Fails to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as observed during a survey. The walk-in freezer had a significant ice build-up attached to the ceiling, causing the ceiling to droop, and the door did not close properly, leaving a large gap. The lighting inside both the walk-in freezer and refrigerator was insufficient, making it difficult to identify contents. Additionally, the vent hood lights were out, and the exhaust fan was not functioning properly, emitting a screeching sound. The air intake and return vents were covered with a thick layer of dark brown/black substance, and the air was directed towards the food holding area. Interviews with staff revealed a lack of communication and awareness regarding the equipment issues. The Assistant DM acknowledged the dim lighting and non-functional vent hood lights but assumed maintenance was aware. The MS admitted to knowing about the ice build-up and the need for new vent hood fixtures but had not taken action. The DM was unaware of the lighting issues and acknowledged the walk-in freezer's poor condition. The ADM, new to the facility, was not informed of the kitchen's repair needs. The maintenance log showed minimal entries, and there were no invoices for repairs to the walk-in freezer or lighting, indicating a lack of maintenance and oversight.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to ensure that eight residents received care in accordance with professional standards of practice and their comprehensive person-centered care plans. Specifically, the facility did not follow physician orders for regular weight monitoring for these residents, which could result in severe weight loss or gain, affecting their quality of life. The residents involved had various medical conditions, including dementia, cerebral palsy, Alzheimer's disease, and diabetes, which necessitated regular weight monitoring as part of their care plans. The deficiency was identified through interviews and record reviews, revealing that the facility did not document weights for the month of June 2024 for several residents. For instance, Resident #4, who had a physician order for monthly weights, did not have a weight recorded for June, resulting in a weight loss of 1.65% over two months. Similarly, Resident #32, who required weekly weights, also had no weight documented for June, leading to a 2.33% weight gain over the same period. These lapses in documentation and monitoring were consistent across the other residents reviewed. Interviews with facility staff, including the DON, Unit Manager, and CNA A, revealed a lack of a systematic approach to ensure weights were recorded as ordered. The DON acknowledged that the facility's electronic patient chart was the only place weights should be recorded, and that CNA A, who was primarily responsible for weighing residents, had fallen behind. Despite verbal communication about the issue, no corrective actions were taken in June, and the problem was only addressed in a QAPI meeting in July. The RD also noted the missing weights and communicated concerns to the administration, but no response was received.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, as evidenced by the presence of ants on a prep table and rodent droppings on the kitchen floor. During an initial observation, ants were found on and around a can opener attached to a prep table, crawling across the table and up a wall into a crack. Additionally, rodent droppings were observed on the floor near a hole in the baseboard. Interviews with staff revealed a lack of awareness and responsibility regarding pest control measures, with the Assistant DM unable to confirm the presence of sticky traps or their maintenance. The facility's pest control log and maintenance log were requested but not provided, and the pest control service contract lacked detailed information on prevention measures. The MS stated that the pest control company treated for ants but was unsure about the presence and location of sticky traps. The DM and ADM were also interviewed, with the ADM acknowledging the need for kitchen repairs but unaware of the extent of the issues. The facility's policy on pest control was requested but not received, indicating a lack of documentation and oversight in maintaining a sanitary environment.
Failure to Accommodate Resident's Call Light Needs
Penalty
Summary
The facility failed to provide services with reasonable accommodation of resident needs and preferences for a resident who was unable to use the call light due to physical limitations. The resident, who had a history of Parkinson's disease, neuralgia, neuritis, lack of coordination, muscle weakness, and a history of falling, was observed in bed with the call light wrapped on the right-side rail, which she could not physically use. Despite attempts to use the call light, the resident was unable to grasp and press it for assistance, which was confirmed by the Director of Nursing (DON) during an observation. Interviews with staff revealed that the resident had been unable to use the call light since admission, and staff sometimes heard her calling out for help or relied on other residents to alert them. The Administrator acknowledged that the resident's condition had changed, possibly due to seizures, affecting her ability to use the call light. However, there was no specific assessment for call light use, and assistance was provided during rounds, which could result in delays. The facility's policy required that call lights be within reach and accessible to residents, with alternative solutions provided if a resident could not use the standard call light. Despite this policy, the resident's inability to use the call light was not adequately addressed, and there was no procedure or policy to ensure residents could use the call light. The resident's care plan and assessments did not reflect her inability to use the call light, leading to a deficiency in accommodating her needs and preferences.
Failure to Respect Resident's Privacy Preferences
Penalty
Summary
The facility failed to ensure the privacy of a resident who had requested that her bedroom door be kept closed. This deficiency was identified during a survey where it was observed that the resident's door remained open wide over several days. The resident, who is cognitively intact with a BIMS score of 13, expressed her preference for the door to be closed due to noise from the hallway. Despite this preference being documented in her care plan, the staff did not adhere to her request, leading to her feeling angry. The resident's care plan, which was last revised in June 2024, clearly indicated her preference for the door to be closed after care, food delivery, and any interactions. The Director of Nursing acknowledged that residents' preferences should be respected and that failure to protect privacy could lead to emotional distress. The resident's medical history includes dementia, stroke, depression, anxiety, and limited range of motion, and she requires assistance with various daily activities.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not changing the oxygen tubing as ordered. The resident, an elderly female with Alzheimer's Disease and Heart Failure, had an active order to change the oxygen tubing and nebulizer circuit every Sunday night shift. However, observations on multiple occasions revealed that the tubing had not been changed since the label dated 06/16/2024, despite the order starting on 05/05/2024. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the tubing should be changed weekly and dated accordingly. Both acknowledged that failure to change the tubing as ordered could lead to the resident becoming sick from dirty tubing. The facility's policy on oxygen administration also stated that oxygen supplies should be changed weekly and labeled with the date when set up or changed.
Unlocked Medication Cart Found at Nurse's Station
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in a locked treatment cart, as observed during a survey. An unlocked medication/treatment cart was found by the nurse's station, with its drawers facing outward, making medications easily accessible. This occurred while a staff member, LVN B, was present at the nurse's station, and two residents were nearby. The surveyor was able to open the drawers and access multiple medications and treatment supplies. Interviews with LVN B and LVN F revealed that the cart was left unlocked due to an emergency situation involving a resident who was bleeding. LVN B admitted to leaving the cart unlocked after retrieving supplies to assist the resident. LVN F confirmed that she had forgotten to lock the cart in the rush to attend to the resident. Both LVNs acknowledged that the treatment/medication carts should be locked at all times to prevent unauthorized access. The Director of Nursing (DON) also stated that carts should be locked when unattended, even during emergencies. The facility's policy, dated 1/1/22, mandates that medication carts must always be locked when out of sight or unattended.
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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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