Amarillo Center For Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Amarillo, Texas.
- Location
- 6641 W Amarillo Blvd, Amarillo, Texas 79106
- CMS Provider Number
- 676347
- Inspections on file
- 49
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Amarillo Center For Skilled Care during CMS and state inspections, most recent first.
Resident Council minutes showed repeated concerns about Nutrition Services, including incorrect meal tickets and meals not matching orders, with no documentation of resolution. Residents reported ongoing problems and felt staff were not listening. The AD said she only documented the meetings and did not follow up, the SW said she never received the notes, and the ADM acknowledged responsibility for ensuring resident concerns were addressed.
The facility failed to ensure accurate pharmaceutical services by leaving multiple blanks on shift-to-shift narcotic count records across 6 medication carts, showing the controlled drug count was not completed at shift change. Staff stated both nurses were supposed to count and sign the narcotic sheet when changing shifts. The facility also failed to complete nightly glucometer QC testing, with logs showing inconsistent high/low control checks across multiple halls, despite policy requiring routine testing.
Kitchen food storage and hygiene deficiencies were observed when opened boxes of food were left unsecured and exposed to air, multiple pantry and spice items were found past their best-by dates or expired, and a staff member was seen in the kitchen without a hairnet. The DM stated all staff were expected to wear hairnets and that foods should be sealed and expired items discarded; facility policy also required hairnets at all times and opened food to be stored in closed, dated containers.
A resident with intact cognition and a fall risk care plan was repeatedly observed with large sharp scissors in her room, despite facility policy allowing only blunt edge scissors and prohibiting scissors or knives in resident rooms. The resident said staff knew about and allowed the scissors for opening packages, and CNA staff confirmed they were aware. Separately, the sharps compartment on the 200 Hall front med cart was found broken and unlocked with used sharps inside, and staff stated the lock was not functioning.
A resident with acute respiratory failure with hypoxia and COPD was left unsupervised when an RN started a nebulizer treatment and left the room, stating she usually does not stay because the treatment takes 10 to 15 minutes. The resident’s care plan and orders included aerosol/bronchodilator treatments and oxygen via nasal cannula, and the facility policy directed staff to work with the patient throughout the treatment until all medication has been nebulized.
A medication cart was found with loose, unidentified pills in a clear plastic cup on the cart. RN F said she did not know the medication was there, and the Corp RN identified the pills as docusate and stated some nurses pour pills into cups during med pass. The facility policy stated meds are administered when prepared and are not pre-poured.
A CNA failed to follow proper hand hygiene during incontinent care for a resident. The CNA cleaned the resident’s buttocks and rectal area, then proceeded to place a clean draw sheet and new brief without performing hand hygiene between the dirty and clean portions of care. In a later interview, the CNA admitted she should have washed her hands when moving from dirty to clean tasks and acknowledged possible cross-contamination. The Corp RN and DON stated their expectation that staff perform hand hygiene before starting care, when transitioning from dirty to clean care, and after completing care, consistent with facility training and perineal care policy requiring hand hygiene before and after glove use.
Four SNAs failed to perform proper hand hygiene and infection control practices during incontinent care for two residents, including not changing gloves or washing hands after contact with soiled materials and improper perineal care technique. Interviews revealed gaps in training and understanding of care procedures, and documentation of required training was missing for several staff members.
Staff failed to perform proper hand hygiene during incontinent care for multiple residents, including not washing hands before or after care, not changing gloves appropriately, and touching clean items after contact with soiled materials. Some staff demonstrated improper perineal care techniques and lacked understanding of infection control protocols, despite facility policies outlining correct procedures.
A resident was not provided privacy during incontinent care when staff failed to close the blinds and door, resulting in the resident being potentially exposed to people passing by the window. The resident, who was cognitively intact and dependent on staff for care, expressed discomfort and concern about being seen. Staff interviews revealed a lack of training and understanding regarding the importance of privacy, despite facility policies requiring it.
The facility failed to treat residents with dignity by serving a cognitively intact resident a meal on disposable dinnerware as a staff convenience, and by not ensuring privacy covers were used on catheter bags for two residents with significant medical needs, despite physician orders. Staff actions and lack of policy guidance contributed to these deficiencies in resident rights and privacy.
The facility's kitchen failed to meet food service safety standards, with numerous items in the dry pantry and cold storage not properly sealed, labeled, or dated. This included items like cream soup base, quick grits, and various cheeses, which were either past their best-by dates or open to air, posing potential health risks.
An unsecured oxygen bottle was found in a resident's room, who did not have orders for oxygen therapy, posing a potential accident hazard. Facility staff confirmed that oxygen bottles should be stored securely to prevent accidents, as per facility policy. The source of the unsecured bottle was undetermined, with speculation that it might have been placed by hospice staff or during admission.
A resident with chronic respiratory failure was observed receiving oxygen at 5L/min instead of the prescribed 3L/min, leading to a deficiency in respiratory care. The discrepancy was noted over two days until an LVN corrected the dose. The DON confirmed that not following the oxygen order is a medication error.
The facility failed to maintain an effective infection prevention and control program, as evidenced by a resident's nasal cannula being on the floor and another resident's catheter bag and tubing also on the floor. Staff interviews confirmed that these practices could lead to contamination and infection, highlighting deficiencies in the facility's infection control practices.
The facility failed to report a resident's fall resulting in a right hip fracture within the required timeframe. Despite the resident's severe cognitive impairment and poor short-term memory, the facility determined the fall was not an injury of unknown origin based on the resident's statement. This decision led to a delay in reporting the injury for 38 days, violating state regulations.
Resident Council Concerns About Meal Orders Were Not Addressed
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly on grievances related to resident care and life in the facility. Record review of Resident Council minutes from 12/04/2025, 01/01/2026, and 02/06/2026 showed repeated concerns about Nutrition Services, specifically incorrect menu tickets and meals not matching what residents ordered, with no documentation showing that these concerns were resolved. The facility’s grievance policy stated that the resident has the right to organize and participate in resident groups and that the facility must consider the views of a resident or family group and act promptly upon grievances and recommendations. During an anonymous interview on 02/19/2026, 5 of 5 residents stated they had ongoing concerns about not receiving the correct meal according to their tickets and felt staff were not listening because nothing had been done. One resident reported that when she ordered an alternative meal, she sometimes did not receive it and instead received the original meal. The AD stated she took notes during meetings and gave them to the ADM or SW, but said she did not believe follow-up was her responsibility and did not know what actions were taken after the meetings. The SW stated she had not received the meeting notes, and the ADM stated it was the ADM’s responsibility to ensure residents’ concerns were addressed and followed through to resolution. The DM stated she was not aware of the dietary concerns and acknowledged residents should receive the meal they ordered and that meal tickets should be accurate.
Incomplete narcotic counts and missed glucometer QC testing
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate acquiring, receiving, dispensing, and administering of drugs and biologicals on 6 of 6 medication carts reviewed. During observation of the shift-to-shift narcotic count books, the Controlled Drugs-Count Record for February 2026 showed multiple blank signature lines on every cart reviewed, including Hall 100, Hall 200 front and back, Hall 300 front and back, and Hall 400, indicating the narcotic count was not completed at shift change. The observed narcotic count records showed 5 blanks on the Hall 100 sheet, 6 blanks on the Hall 200 back sheet, 2 blanks on the Hall 200 front sheet, 25 blanks on the Hall 300 front sheet, 12 blanks on the Hall 400 sheet, and 25 blanks on the Hall 300 back sheet. Staff interviews reflected that nurses were expected to count narcotics together at shift change and both sign the sheet, with one nurse stating the count must be correct before taking over the medication cart. The facility also failed to complete glucometer quality control testing every night. Review of the Glucometer Quality Control Log High/Low Controls for February 1st through 19th showed inconsistent testing across the halls, including Hall 100 checked 3 of 19 days, Hall 300 back 10 of 19 days, Hall 300 front 0 of 19 days, Hall 200 back 10 of 19 days, Hall 200 front 10 of 19 days, and Hall 400 1 of 19 days. Staff interviews confirmed that night shift was responsible for checking the glucometers, and the facility policy required routine quality control testing using high and low control solutions.
Kitchen Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions in the kitchen. During observation of the walk-in freezer, opened boxes of peanut butter cookie dough, corn, and frozen biscuits were found open to air and unsecured. In the pantry, dented cans of [NAME] Chacherie creole seasoning were observed with a best if used by date of 10/2024, along with Smucker's plate syrup dated 9/30/25 and horseradish dated 7/20/25. On the kitchen shelving holding spices, sesame seeds were dated June 2025, cloves were dated September 2025, celery seeds were expired in January 2025, and thyme had a best by date listed as [DATE]. The same conditions remained present on a later observation with no corrections noted. The facility also failed to ensure hairnets were worn by all staff in the kitchen. During an observation and interview, [NAME] A was seen in the kitchen without a hair net covering his hair, and he stated he should have had a hairnet on while in the kitchen. The DM stated that all employees were expected to wear hairnets in the kitchen, that foods should be closed to air and securely sealed, and that expired foods should have been thrown out and not used. The DM also stated the dietician had trained her in the kitchen and she had trained the staff. Facility policy titled Dietary Food Services Personnel Policy and Procedures stated hairnets are worn at all times, and the Dry Storage and Supplies policy stated opened packages of food are stored in closed containers with tight covers and dated as to when opened.
Unsafe Sharp Objects and Broken Sharps Storage
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision to prevent accidents for Resident #60. Resident #60 was an [AGE]-year-old female admitted with diagnoses including depression, anxiety disorder, weakness, and a personal history of thyroid cancer. Her admission MDS showed a BIMS of 14 out of 15, indicating intact cognition, and her care plan identified her as a fall risk with interventions for a safe environment. The facility admission packet stated that scissors or knives were not allowed in resident rooms and that only blunt edge scissors were permitted. Despite this, Resident #60 was observed multiple times with a pair of large cutting scissors with sharp edges in her room and on her bed or lap. She stated the scissors belonged to her and that she used them to open packages because she could no longer tear items open, and she stated staff were aware and had allowed her to keep them. CNA staff confirmed they knew she had the scissors and acknowledged that sharp scissors were against facility policy and could result in injury. In addition, the sharps storage compartment on the 200 Hall Front Medication Cart was observed unlocked and broken, with used sharps inside; staff stated the lock was not functioning and that the condition could cause needlestick injury. The DON and ADM confirmed staff were expected to follow facility policy regarding prohibited items and safety hazards.
Resident Left Unsupervised During Nebulizer Treatment
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #85 when RN J initiated a breathing treatment and then left the resident’s room, leaving the resident unsupervised during the treatment. Resident #85 was admitted with diagnoses including acute respiratory failure with hypoxia and COPD, and his MDS assessment documented shortness of breath or trouble breathing with exertion, at rest, and when lying flat. His care plan directed staff to give aerosol or bronchodilator treatments as ordered and to monitor and document side effects and effectiveness, and his order summary included oxygen via nasal cannula every shift and budesonide inhalation suspension every 6 hours. During observation, RN J provided new tubing and a mask, started the breathing treatment, and told the resident she would return in 10 to 15 minutes to check on him. In interview, RN J stated she usually did not stay in the room because the treatment takes 10 to 15 minutes to complete. The Administrator stated he was aware nurses needed to stay with residents when they are receiving breathing treatments, and the Corp RN stated she had spoken with the nurse and would start an in-service about the need for nurses to stay with residents during breathing treatments. The facility policy for aerosolized hand-held nebulizer treatments stated to encourage and work with the patient throughout the treatment and to continue treatment until all medication has been nebulized.
Unlabeled Medication Found in Medication Cart
Penalty
Summary
The facility failed to ensure medication was labeled and stored in accordance with currently accepted professional principles for 1 of 6 medication carts reviewed. During observation of the Hall 200 front medication cart with RN F present, a clear plastic drinking cup was found on the cart containing loose medication, about 3/4 full of unidentified pills. RN F stated the medication in the cup was Colace and said she did not know it was in her medication cart. During interview, the Corp RN identified the pills as docusate and stated there was a large bottle in the bottom drawer of the medication cart. The Corp RN also stated she had found that some nurses pour pills into cups to use during medication pass and then throw the pills out when finished. RN F later stated the medication in the plastic drinking cup was not given by her and that she disposed of it. The facility policy stated medications are administered at the time they are prepared and are not pre-poured.
Improper Hand Hygiene During Incontinent Care
Penalty
Summary
A deficiency occurred when CNA A failed to follow proper hand hygiene practices during incontinent care for a resident. During an observation, CNA A performed hand hygiene and then assisted the resident to roll onto her side. While wearing gloves, CNA A used wipes to clean the resident’s left buttocks, right buttocks, and rectal area. Without performing hand hygiene between dirty and clean tasks, CNA A then placed a clean draw sheet and a new brief under the resident. After this, CNA A removed her gloves, washed her hands, donned new gloves, rolled the resident onto her back, and secured the new brief. In a subsequent interview, CNA A acknowledged that when moving from the dirty portion of care to the clean portion, she should have washed her hands and that she was “dirty” after wiping the resident, stating she probably cross-contaminated. CNA A reported she had been trained in hand hygiene by the former DON. In a group interview, the Corp RN stated she expected staff to perform hand hygiene before beginning incontinent care, when moving from any dirty to clean portion of care, and upon completion of care, to prevent cross contamination. The DON agreed and added that he expected staff to use ABHR before entering a resident’s room. Training records showed CNA A had received hand hygiene education, and facility policy on perineal care required hand hygiene before and after glove use.
Failure to Ensure Nursing Staff Competency in Infection Control During Incontinent Care
Penalty
Summary
The facility failed to ensure that nursing staff, specifically student nurse aides (SNAs), possessed the appropriate competencies and skill sets to provide safe and effective care for residents. Observations revealed that four SNAs did not perform proper hand hygiene before, during, or after providing incontinent care to two residents. Additionally, one SNA wiped back to front during perineal care, and clean briefs were handled without changing gloves or performing hand hygiene after contact with soiled materials. These actions were directly observed during care activities, and staff were seen touching residents' clothing, bedding, and personal items without appropriate infection control measures. Interviews with the involved SNAs indicated a lack of understanding regarding the negative outcomes of improper hand hygiene, and one SNA reported not having been taught how to perform perineal care. Documentation of training for three SNAs could not be located, and the DON confirmed that orientation and clinical training were required but could not provide evidence for all staff. Facility policy required that SNAs only perform care for which they had received training, but this was not consistently followed or documented.
Failure to Perform Hand Hygiene During Incontinent Care
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols during incontinent care for three residents. Observations revealed that staff did not perform hand hygiene before starting care, after cleaning soiled areas, or after removing gloves. Staff were also seen touching clean briefs, residents' clothing, bedding, and personal items without changing gloves or performing hand hygiene. In one instance, a staff member used a single wipe multiple times and wiped from back to front, contrary to policy. Additionally, a clean brief was placed on a resident while the dirty brief was still in place, resulting in contact between the clean and soiled briefs. Interviews with staff indicated a lack of understanding regarding the negative outcomes of not performing hand hygiene, with some staff unable to articulate the risks or proper procedures. Record review confirmed that facility policies require hand hygiene before and after resident care, after glove removal, and specify correct perineal care techniques. Despite these policies, staff actions did not align with the documented procedures, leading to the identified deficiency.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
Staff failed to provide privacy for a female resident during incontinent care, as observed when two staff members did not close the blinds or the door to the resident's room. During this time, an unidentified person walked by the resident's bedroom window twice, potentially exposing the resident. The resident, who was cognitively intact and required significant assistance with most activities of daily living, expressed that she expected staff to close the blinds and door during care and did not want to be seen naked by people passing by, especially men who frequently took out trash and laundry near her window. Interviews with the staff involved revealed that one staff member was trained to leave the blinds open during the day, even during personal care, and could not identify any negative outcomes from not providing privacy. Another staff member stated she had not been trained on how to perform incontinent care and also could not identify negative outcomes. The facility's policies on resident rights and perineal care both require providing privacy and modesty by closing doors and/or curtains during care. The Director of Nursing acknowledged that not providing privacy could lead to embarrassment and a lack of dignity for the resident.
Failure to Honor Resident Rights and Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity, resulting in multiple deficiencies related to resident rights. One cognitively intact female resident with mild cognitive impairment and major depressive disorder was served a meal on a Styrofoam plate with plastic utensils, rather than regular dinnerware, after a CNA unilaterally decided to request disposable items for her. This decision was made after the resident, unable to reach her call light due to hip pain, used her knife to tap on her plate to summon assistance. The CNA, without consulting the charge nurse, documented the request for disposable dinnerware on the resident's dining slip, which led to the resident feeling embarrassed when served her next meal in this manner. Additionally, the facility failed to ensure the visual privacy of catheter bag contents for two female residents with significant medical conditions, including severe cognitive impairment and end-of-life care. Both residents had physician orders requiring the use of privacy covers on their catheter bags while in bed or in a wheelchair. Observations revealed that neither resident had privacy covers in place, making the contents of their catheter bags visible to others. In one case, the catheter bag was visible from the hallway when the resident's door was open, and in the other, the bag was exposed while the resident was at the nurse's charting station. Interviews with staff indicated a lack of awareness and follow-through regarding the use of privacy covers, with one CNA stating he was unsure if the resident minded the lack of a cover and another resident's representative reporting unsuccessful attempts to obtain a privacy cover from staff. The facility's policy on resident rights did not include specific guidance on the use of regular dinnerware or privacy covers for catheter bags.
Food Storage and Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not ensure that all food items in the dry pantry and cold storage areas were properly sealed, labeled, and dated. This included various food items such as cream soup base, quick grits, elbow macaroni, pepper gravy mix, creamy wheat cereal, English cucumbers, hot dogs, lime juice, sausage links, Queso Cotija cheese, feta cheese, and scrambled eggs. Many of these items were either past their best-by dates, had no dates, or were open to air, which could potentially compromise their safety and quality. During an interview, the Dietary Manager acknowledged the risks associated with consuming unlabeled and undated foods, including the possibility of residents becoming ill from expired foods and the deterioration of food quality. The manager confirmed that the kitchen staff had not been following proper food storage protocols, which require resealing, labeling, and dating all products, using items within their use-by dates, and ensuring airtight storage. The lack of adherence to these protocols was evident in the findings from the kitchen inspection.
Unsecured Oxygen Bottle Poses Accident Hazard
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that residents received adequate supervision to prevent accidents. Specifically, an unsecured oxygen bottle was found in the room of a resident who did not have orders for oxygen therapy. The resident, who had been admitted to the facility six days prior, was unaware of the oxygen bottle's presence and did not know who placed it there. The unsecured oxygen bottle was observed lying at the foot of an unoccupied bed in the resident's room, posing a potential risk for accidents. Interviews with facility staff, including a CNA, an LVN, and the DON, confirmed that oxygen bottles should be stored securely to prevent accidents. The staff members acknowledged that an unsecured oxygen bottle could fall and potentially cause injury. The facility's policy on the safe handling of compressed gas requires that all tanks and cylinders be stored in a secure manner, either in a cylinder cart or chained in a secure storage area. Despite this policy, the source of the unsecured oxygen bottle in the resident's room could not be determined, with the DON speculating that it might have been placed there by hospice staff or during the resident's admission.
Failure to Administer Correct Oxygen Dose
Penalty
Summary
The facility failed to administer oxygen at the correct dose for a resident, leading to a deficiency in providing safe and appropriate respiratory care. The resident, a female with chronic respiratory failure and hypoxia, was observed receiving oxygen at 5L/min via nasal cannula, despite the physician's order specifying 3L/min. This discrepancy was noted during multiple observations over two days, where the resident was consistently receiving a higher oxygen dose than prescribed. The issue was identified when an LVN checked the resident's oxygen level and realized it was set too high. The LVN confirmed the correct order from the resident's chart and adjusted the oxygen level accordingly. The Director of Nursing (DON) emphasized the importance of following physician orders and acknowledged that not adhering to the prescribed oxygen dose constitutes a medication error. The facility's policy on oxygen administration aims to ensure safe and effective delivery of prescribed oxygen, which was not adhered to in this instance.
Infection Control Deficiencies in Oxygen and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. Resident #45, a female with Alzheimer's, heart failure, and major depressive disorder, was observed with her nasal cannula on the floor, which was discolored and in direct contact with the floor. Despite having orders for oxygen therapy, her care plan did not mention oxygen use, and she stated she did not need or wear oxygen. Interviews with staff, including an LVN and the DON, confirmed that nasal cannulas should be stored in a plastic bag off the floor to prevent contamination and infection. In another incident, Resident #221, a male with a history of surgical aftercare and multiple cancers, was observed with his catheter bag and tubing on the floor. He reported not being informed that this was inappropriate. The facility's policy on catheter care explicitly states that tubing and drainage bags should be kept off the floor. Interviews with CNAs and the DON highlighted the risk of infection and other negative outcomes from catheter bags being on the floor. However, the ADON incorrectly stated that there was no negative outcome from a catheter bag on the floor, contradicting other staff members. The facility's infection control plan and policies on catheter care and oxygen administration were reviewed, revealing that the oxygen administration policy did not address tubing storage or infection control. These deficiencies in infection prevention and control practices could place residents at risk of infections and other complications, as noted by the surveyors.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an alleged violation of injury of unknown origin within the required timeframe for a resident who experienced a fall resulting in a right intertrochanteric fracture. The incident occurred on 2-27-2024, but the facility did not report the injury until 38 days later. The resident, who was severely cognitively impaired with a BIMS score of 4, was found on the floor by a CNA and assessed by an LVN. Despite the resident's poor short-term memory and inability to recall events, the facility determined that the fall was not an injury of unknown origin based on the resident's statement about not wearing socks and falling while returning from the bathroom. Interviews with staff and family members revealed that the resident had a history of poor short-term memory and often became confused. The MDS Coordinator and Social Worker both confirmed that the resident's cognitive impairment would likely prevent her from accurately recalling the events leading to her fall. Despite this, the facility's Administrator reported that the incident was not considered an injury of unknown origin and therefore was not reported as required by state law. The facility's policy on abuse and neglect requires that all allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and injury of unknown origin be reported to the facility administrator, who must then report to the state agency within 2 hours if the allegations involve abuse or result in serious bodily harm. The failure to report the resident's fall and subsequent fracture in a timely manner was a clear violation of this policy and state regulations.
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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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