Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ambrosio Guillen Texas State Veterans Home during CMS and state inspections, most recent first.
Three residents who needed help with personal hygiene were observed with long, untrimmed fingernails. Two residents had diabetes and one had a left-hand contracture; all three stated they wanted their nails trimmed and had not received the care in a timely manner. Staff gave inconsistent accounts of who could provide nail care for residents with diabetes, while the DON stated nurses were responsible for completing it and the facility policy directed diabetic residents to the licensed nurse or podiatrist.
Improper food storage and food handling practices were observed in the kitchen. A zip-top bag of boiled eggs and a container of fruit salad were left unsealed in the walk-in refrigerator, and a Dietary Director confirmed both items were not properly covered. During meal service, an LVN wore a torn hairnet with hair exposed while handling meal trays, and dietary staff exited and reentered the kitchen while wearing gloves without performing hand hygiene or changing gloves before continuing to serve bread rolls to residents. Facility policy required covered leftovers, hair restraints, and glove changes after contamination.
A resident with Alzheimer’s dementia and an indwelling catheter was observed in a common area with a clear Foley catheter bag exposed under his wheelchair without a privacy cover. Staff later confirmed that the privacy bag or privacy flap was meant to conceal the catheter bag for privacy and dignity, and the resident’s care instructions called for use of a privacy bag.
Call Light Not Kept Within Reach: A resident with MS, intact cognition, and dependence for toileting, hygiene, and bed mobility was observed lying in bed with the call light placed behind a chair and out of reach. The resident stated she used the call light to ask staff for help, and interviews with a CNA, an LVN, the DON, and the Administrator confirmed that call lights were to remain within reach and that all staff were responsible for ensuring accessibility.
Incomplete and outdated care plans were identified for two residents with dementia-related needs. One resident's care plan did not include dementia or dialysis as focus areas despite records showing those diagnoses, and another resident's care plan had not been completed within the prior 3 months. Observation and interviews showed the second resident was fixated on money and family stressors, while the guardian reported not being included in a care plan meeting. Staff confirmed care plans needed updating with changes in condition and behaviors.
Care Plan Not Updated After Assessments: A resident with dementia, depression, and mild cognitive impairment had a care plan that had not been updated for months despite ongoing fixation on money and family stressors, and the guardian reported not being invited to a care plan meeting. Staff interviews confirmed the IDT was responsible for maintaining the comprehensive care plan and that it had not been revised to reflect the resident’s current condition and behaviors.
A resident with rheumatoid arthritis had a Lidocaine patch order requiring removal at 8:00 PM, but staff found and removed the prior day’s patch the next morning before applying a new one. In addition, an LPN did not sign the controlled medication accountability record at the start of the shift after counting controlled substances on the cart, and staff stated the sign-off was meant to verify narcotic counts and help prevent diversion.
A medication cart on the 300-hall was found with blister packet pieces, a loose tablet in the drawer, and a dried yellow drip on the cart. LVN C stated the nurse or med aide using the cart was responsible for keeping it clean each shift, and the DON said the pharmacy nurse completed monthly cart reviews. The facility policy required meds to be administered to prevent contamination or infection and the cart to be kept clean and organized.
Nursing staff performed blood glucose checks and insulin injections for four cognitively impaired, diabetic residents in a TV/common room, in full view and hearing range of more than 15 other residents. These residents, who had documented dementia, communication impairments, and daily insulin needs, received treatments that exposed their skin and disclosed their glucose readings, insulin type, and dosage in a public area. Facility leadership, including the Supervisor RN, Unit Manager, ADON, and Administrator, acknowledged that such care should occur in residents’ rooms to maintain privacy, dignity, and confidentiality, and that the observed practice conflicted with resident rights and facility policy.
An LVN performed wound care on a resident with a Stage 4 sacral pressure injury while wearing an unsecured gown, failed to perform hand hygiene or change gloves after removing soiled dressings and cleaning the wound, removed and discarded the gown mid‑procedure, and continued care without a gown until stopped by a surveyor. Separately, an RN conducted serial blood glucose checks and insulin injections for four residents with diabetes and cognitive impairment without sanitizing hands between glucose testing and insulin preparation, after injections, or between residents, and sometimes touched the medication cart and room door handles without prior hand hygiene. In interviews, the LVN and RN acknowledged they did not follow expected infection control practices, while supervisory staff and leadership described that facility policy and standard practice required multiple hand hygiene opportunities and appropriate PPE use during wound care and glucose monitoring with insulin administration.
A resident with diabetes and chronic left foot wounds was diagnosed with osteomyelitis by an outside podiatrist, with imaging confirming calcaneal involvement and possible 5th toe osteomyelitis. The podiatrist’s note documented the diagnosis and a plan to consult infectious disease, but facility records contained no timely nursing progress note showing that the NP/MD was informed when this diagnosis was first identified. Staff interviews confirmed that the receiving nurse was responsible for reviewing outside notes and immediately notifying the NP/MD of new diagnoses, yet the NP reported learning of the osteomyelitis from the resident’s family rather than from facility staff. The DON stated she believed immediate notification was unnecessary because the condition was described as stable and there were no new orders, despite facility policy requiring physician notification for new conditions and skin issues.
A resident with diabetes, open foot wounds, and hospital-confirmed left calcaneal osteomyelitis received IV therapy and related interventions per the care plan, but the discharge MDS did not include osteomyelitis as an active diagnosis. The MDS LVN reported relying on floor nurses to update diagnoses and reviewing MDS assessments only quarterly, viewing missing diagnoses primarily as a reimbursement issue and noting no in-service training on accurate MDS completion. The Administrator focused mainly on BIMS scores, was unsure that diagnoses must be included on the MDS, acknowledged that omissions fail to show the full clinical picture, and could not recall the last in-service, despite a facility policy requiring comprehensive assessments per RAI criteria when significant changes occur.
A resident with diabetes, hyperglycemia, and left foot wounds had MRI-confirmed calcaneal and possible 5th toe osteomyelitis and was seen by a podiatrist, whose note indicated osteomyelitis and a plan to consult infectious disease. Facility progress notes did not document that the NP/MD was notified of this new or confirmed diagnosis following the outside appointment, despite staff interviews and facility expectations indicating nurses must review outside provider notes, immediately notify the NP/MD of new diagnoses, and record this in the medical record. The DON stated she believed immediate notification was unnecessary because the condition was described as stable and there were no new orders, while the Administrator stated that immediate notification and documentation were required. This lack of documentation of NP/MD notification regarding the osteomyelitis diagnosis led to the cited deficiency in maintaining a complete and accurate medical record.
A resident with a history of behavioral and medical issues alleged that an LVN squeezed her hand, resulting in bruising. Staff documented the incident and notified supervisors, but the facility did not report the abuse allegation to the State Survey Agency within the required timeframe, citing the resident's combative behavior as an alternative explanation for the injuries. The facility's policies for immediate reporting of abuse allegations were not followed.
The facility did not complete required annual employee misconduct registry and nurse aide registry screenings for two CNAs, as mandated by its own policies. This lapse was confirmed through record reviews and staff interviews, revealing that annual screenings were missing from the employee files, which could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.
Two residents experienced deficiencies in accident prevention and supervision when one was found on the floor after a fall due to an inaccessible call light and missing assist bars, while another lost independence in bed mobility after bed rails were removed and no timely PT/OT evaluation was completed. Staff interviews confirmed delays in therapy assessments and inconsistent implementation of fall prevention policies.
A registered nurse delegated a blood glucose check to a CNA, contrary to facility policy, and later administered insulin based on the result. In a separate incident, the same nurse gave an insulin injection to another resident through clothing without cleaning the site, also violating proper procedure. The facility lacked a skills checklist for insulin administration and did not maintain written documentation of staff re-education or investigation related to these incidents.
A resident with dementia and type 2 diabetes did not receive insulin as ordered when an LVN failed to check blood glucose before dinner and did not administer sliding scale insulin. On another occasion, rapid-acting insulin was given well before the resident received a meal, and no snack was provided within the recommended timeframe. These actions resulted in significant medication errors due to noncompliance with physician orders and manufacturer specifications.
A resident with intact cognition reported his wallet, containing identification documents, a Social Security card, a checkbook, and cash, as missing. Despite internal investigation and searches by staff, the wallet was not found, and the incident was not reported to the State Survey Agency as required by facility policy. The administrator determined the situation did not meet the threshold for misappropriation due to the lack of a clearly identified perpetrator, even though the policy required reporting all such allegations.
The facility failed to serve meals simultaneously to residents in the memory care unit, causing some to wait up to 30 minutes while their tablemates ate. This affected 7 out of 15 residents reviewed for residents' rights. Interviews revealed that the responsibility for ensuring simultaneous meal service lies with the nursing and kitchen staff, who failed to coordinate effectively.
The facility failed to ensure residents were aware of the grievance process, as five residents reported not knowing how to file a grievance or who to contact. Interviews with staff revealed inconsistencies in communicating the grievance process, and the facility's policy on Resident Rights was not effectively conveyed to residents.
The facility failed to post required oxygen signs outside the rooms of two residents using oxygen therapy, as observed by surveyors. This deficiency was confirmed by staff interviews, which highlighted the potential risks of unchecked oxygen levels and fire hazards. The facility's policy mandates such signage to ensure safety and proper monitoring.
The facility failed to ensure proper pharmaceutical services and record-keeping, including not signing controlled drug records and temperature logs. A resident's medication count was inaccurate due to a staff member not updating the control drug record after administering Tramadol. Additionally, the temperature log for vaccines/medications was not signed, potentially risking therapeutic responses and increasing drug diversion risks.
The facility failed to maintain clean medication and treatment carts, with liquid medication bottles found with dried drippings, posing a risk of cross-contamination. LVNs acknowledged their training to keep bottles clean, but observations revealed otherwise. The facility's policy lacked specific instructions on maintaining bottle cleanliness.
The facility failed to serve meals at the required temperature during a lunch service, with pureed, regular, and mechanical soft meals, including fried zucchini and Albondiga soup, served below 135°F. The CDM Interim acknowledged the oversight and the facility's policy requiring hot foods to be served at 135°F or higher, noting the potential risks of foodborne illnesses.
A resident with multiple health conditions, including muscle weakness and coronary artery disease, was found with her call light tangled and on the floor, making it inaccessible. Despite staff training and facility policy requiring call lights to be within reach, the resident confirmed she could not reach it and would have to wait for staff to pass by for help. Interviews with staff, including CNAs, an RN, and the DON, acknowledged the policy but it was not followed, posing a risk of unmet needs.
The facility failed to document behavioral incidents for two residents in their MAR/TAR, despite these incidents being tracked for irritability, aggression, and delusional disorders. The DON acknowledged the importance of accurate documentation for care planning, as per facility policy.
A resident with a catheter was found with the drainage bag on the floor, contrary to the facility's care plan and catheter care policy. Staff interviews revealed that the bag should have been attached to the bedframe to prevent infection. The facility's policy emphasized proper technique to prevent infections, which was not followed.
A resident receiving oxygen therapy did not have the required 'Oxygen in Use' sign posted outside their room, as observed during a survey. The resident had a history of respiratory issues and was on oxygen therapy per physician's orders. The ADON acknowledged the oversight, which was contrary to the facility's policy, although the risk was deemed minimal due to the smoke-free environment.
A facility failed to document a physician's order for PRN oxygen for a resident with respiratory issues. The resident's oxygen levels dropped, and a nurse administered oxygen but did not enter the order into the system. The DON confirmed the oversight, noting the nurse was busy stabilizing the resident. Despite the documentation lapse, the resident received continuous oxygen without negative outcomes.
The facility failed to ensure accurate MDS assessments for two residents, one with a g-tube and another with behavioral issues. These inaccuracies were confirmed by the Unit Manager and MDS Nurse, potentially affecting the residents' care and management.
The facility failed to document and implement care interventions for a resident who repeatedly pulled on a drainage tube, despite staff being aware of the behavior. The behavior was not included in the care plan, leading to multiple incidents requiring medical intervention.
The facility failed to implement their abuse prevention policies by not immediately suspending a CNA after a report of suspected roughness with a resident. The resident, who had severe cognitive impairment and behavioral symptoms, was reportedly grabbed strongly by the CNA. Despite the report, the CNA was allowed to finish her shift, and the investigation was deemed unsubstantiated due to inconsistencies in statements and lack of observed distress in the resident.
Failure to Provide Timely Nail Care for Residents Needing ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received needed nail care, as three residents were observed with fingernails that were long and not trimmed. Resident #63, who had a history of congestive heart failure and muscle weakness and was documented as dependent for personal hygiene, was observed with fingernails about a quarter of an inch past the fingertips on both hands and stated he wanted them trimmed and had not had them trimmed in about a month. Resident #65, who had a history of stroke and type II diabetes mellitus and required substantial to maximal assistance with personal hygiene, was observed with long fingernails on the left hand, including a left-hand contracture. He stated he wanted his nails trimmed and could not recall the last time they had been trimmed. Resident #148, who had diabetes mellitus and cerebrovascular disease and required substantial to maximal assistance for personal hygiene, stated he wanted his nails cut but had waited a long time because only the nurse could cut them due to his diabetes diagnosis. He said he had asked the prior week but had not received the service, and his right-hand nails were observed to be longer than the left-hand nails. Staff interviews showed differing understanding of nail care responsibilities for residents with diabetes. A CNA stated she assisted with nail trimming and would notify the nurse if a diabetic resident requested nail care, while an LVN stated nurses could provide nail trimming and that CNAs could not trim or file nails for diabetic residents. The DON stated nail care could be provided by CNAs and nurses, but if a resident was diabetic the nurses needed to complete it. The facility’s nail care policy stated that nail care would be provided to residents, with diabetic residents referred to the licensed nurse or podiatrist.
Improper Food Storage and Food Handling Practices
Penalty
Summary
Food was not stored in accordance with professional standards in the kitchen. During an observation in the walk-in refrigerator, a zip-top bag containing boiled eggs was seen open and not properly sealed, with a date of 04/06/2026. Nearby, a plastic container of fruit salad was also observed unsealed, with the wrapping open at one corner and the contents exposed. The Dietary Director stated that both items had not been properly sealed and that storing food in an unsealed condition increased the risk of contamination from insects and other environmental factors such as frost bite. Dietary staff also did not maintain proper hygiene while handling meal service items. During an observation in the kitchen, LVN A was handling meal trays while wearing a torn hairnet that left hair exposed on the right side of his head. The Dietary Director stated that all personnel entering the kitchen were required to wear appropriate hair restraints, including hairnets and beard guards when applicable, and that a torn hairnet compromised infection control standards because it increased the likelihood of hair falling into food and contaminating meal trays. LVN A stated he had been informed that his hairnet was torn and that his hair was exposed. During meal service in the memory unit dining room, dietary staff exited and reentered the kitchen three times while wearing serving gloves and did not perform hand hygiene before reentering the meal serving area. The staff member was observed grabbing bread rolls with gloves that had been contaminated by touching the door handle and other surfaces outside the food service area for approximately 20 residents. In interview, the staff member stated he did not practice hand hygiene or change gloves after leaving and reentering the area and acknowledged that he should have removed the gloves, washed his hands, and applied new gloves before resuming work. Facility policy required leftover food to be covered, labeled, and dated, required hair restraints to prevent hair from contacting exposed food, and required gloves to be changed and hands washed whenever a contaminated surface was touched.
Foley Catheter Bag Left Exposed Without Privacy Cover
Penalty
Summary
The facility failed to treat Resident #127 with respect and dignity when, on 04/07/2026, he was observed sitting in the common area watching TV in his wheelchair with a clear Foley catheter bag exposed underneath the wheelchair and no privacy cover in place. A follow-up observation later that afternoon showed the resident still in the common area with the catheter bag exposed. Resident #127 had an original admission date of 12/05/2025, diagnoses including Alzheimer’s dementia, overactive bladder, and benign prostatic hyperplasia, and an MDS BIMS score of 3 indicating severe cognitive impairment. His care plan included a focus area related to disorientation from dementia and interventions to provide choices and assist with decision making. Record review of the March 2026 MAR/TAR showed Resident #127 had an indwelling catheter with instructions to keep the Foley bag below the bladder and utilize a privacy bag. During the observations, the resident’s clear Foley catheter bag was visible without the privacy bag in place while he remained in the common area. On 04/08/2026, the resident was later observed with the clear Foley catheter bag placed in a privacy bag suspended under his wheelchair. During a later observation in his private restroom, LVN F confirmed the Foley catheter bag inside the privacy satchel was clear and not the facility’s standard issued white with blue privacy flap. Staff interviews showed CNA D, LVN C, LVN F, and the DON all identified the privacy bag or privacy flap as the means to cover the Foley catheter bag and stated it was used to protect the resident’s privacy and dignity by preventing others from seeing urine output or color. CNA D stated CNAs and nurses were responsible for ensuring residents had the privacy bag in place, and LVN F stated it needed to be provided immediately once the facility was aware of the catheter. The DON stated that if a resident had a clear Foley catheter bag, the facility usually switched it to the white with blue flap version when the resident returned from the hospital, and that any nurse could change it or provide the privacy satchel. The facility’s Resident’s Rights policy stated residents have the right to respect, dignity, privacy, and confidentiality, and the in-service record showed CNA D and LVN C had been educated on providing privacy and resident rights.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that Resident #15 had the call light within reach. Resident #15 was admitted on 09/19/2025 and readmitted on 09/25/2025, with a history and physical dated 03/03/2026 showing a diagnosis of multiple sclerosis. The comprehensive MDS showed a BIMS score of 15, indicating intact cognitive function, and Section GG indicated the resident was dependent with toileting, hygiene, and bed mobility. The care plan, revised on 03/23/2026, identified the resident as at risk for injury/falls related to impaired mobility and general weakness from multiple sclerosis and included keeping the call light within reach when in bed. During observation on 04/07/2026 at 10:19 a.m., Resident #15 was lying in bed and the call light was behind the chair to the right of the bed, out of reach. The resident stated she did not know how the call bell got there and that she could not reach it, and she said she used the call light to ask staff for help. Interviews with a CNA, an LVN, the DON, and the Administrator confirmed that the call light was intended to be kept within reach so the resident could request assistance, and that all staff were responsible for ensuring it remained accessible.
Incomplete and Outdated Care Plans for Residents With Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for 2 of 6 residents reviewed for dementia care. For Resident #14, record review showed an admission record listing unspecified dementia, mild, and a quarterly MDS indicating the resident was unable to participate in a BIMS and had non-Alzheimer's dementia. The resident's health and physical dated 03/23/26 also documented a history of dementia, but the care plan last revised 03/17/2026 did not include dementia as a diagnosis or focus area. For Resident #24, record review showed an annual MDS with a BIMS score of 09 and active diagnoses of dementia, depression, and other symptoms and signs with cognitive functions and awareness. The resident's physical and health record dated 04/02/2026 documented complaints about his POA guardian not giving him enough money. The published care plan dated 07/2025 with a target completion date of 10/23/2025 included a focus area for increased confusion and disorientation related to dementia and a focus area for major depressive disorder, but the care plan had not been completed within the previous 3 months. During observation and interviews, Resident #24 was repeatedly noted to be fixated on money, family members, and his spouse in Mexico, with restlessness, difficulty regulating emotions, and frustration. The guardian stated he had not participated in a care plan meeting within the prior 4 months and had not been contacted to schedule one. Staff interviews confirmed that care plans needed to be updated with changes in condition and behaviors, that a resident missing a dialysis diagnosis needed to be care planned, and that a care plan not updated since July 2025 would not meet facility expectations. The DON stated that if a resident's care plan was missing a dementia diagnosis, the facility could not create a plan of care and would not be able to address the behaviors and implications of dementia.
Care Plan Not Updated After Assessments
Penalty
Summary
The facility failed to review and revise the interdisciplinary care plan after assessments for Resident #24, and the resident did not have a comprehensive person-centered care plan completed within the previous 3 months. Resident #24 was an older male with an original admission date of 04/05/2021 and a readmission on a later date. His annual MDS showed a BIMS score of 09, indicating mild cognitive impairment, and listed active diagnoses of dementia, depression, and other symptoms and signs with cognitive functions and awareness. Record review showed that the resident’s published care plan was dated 07/2025 with a target completion date of 10/23/2025. That care plan included a focus area for risk of increased confusion and disorientation related to dementia, with a behavior noted as asking staff to take him to a border city in a neighboring country and bribing staff with money. It also included a focus area for major depressive disorder with an intervention to observe for changes in mental status. A physical and health note dated 04/02/2026 documented that the resident had been complaining about his POA guardian not giving him enough money. During observations and interviews on 04/07/2026, 04/08/2026, and 04/09/2026, Resident #24 remained fixated on his money, family member, and spouse in Mexico and was observed with restlessness, difficulty regulating emotions, and frustration. The guardian stated he had not participated in a care plan meeting within the prior 4 months and had not been contacted to schedule one. Staff interviews confirmed that care plans needed to be updated with changes in condition and behaviors, that the resident’s care plan had not been updated since 07/2025, and that the facility’s interdisciplinary team was responsible for developing and maintaining comprehensive care plans. The facility policy stated that the interdisciplinary team develops and maintains a comprehensive care plan for each resident and that the care plan is developed within 7 days after completion of the MDS assessment and revised as changes are indicated.
Medication Reconciliation and Patch Removal Failure
Penalty
Summary
Pharmaceutical services were not provided in a manner that met resident needs because the facility did not maintain an established system for accurate reconciliation of controlled substances on 1 of 2 medication carts with residents ordered controlled medications. During review of the Controlled Medication Accountability Record, LVN C did not sign the record at the beginning of the shift after counting and verifying the controlled substances in the medication cart. LVN C stated nurses were supposed to sign at the beginning of the shift, but she usually signed in the middle of her shift so she could account for any additional medications received during the shift. The facility also failed to ensure Resident #157’s Lidocaine External Patch was removed according to the physician’s order. Resident #157 was an older male with rheumatoid arthritis, a BIMS score of 13, and a care plan identifying risk for altered comfort/pain related to arthritis. His medication order directed that the Lidocaine External Patch 4% be applied in the morning and removed at 8:00 PM. The MAR showed the patch was marked removed at 8:00 PM by LVN J, but on observation the next morning LVN H removed a patch dated the prior day from the resident’s right shoulder and LVN C applied a new patch. Interviews confirmed staff understood the ordered removal time and their responsibilities related to medication administration. LVN H stated the nurse signing off the MAR was responsible for removing the patch per the physician’s order. LVN C stated the nurse on shift administering or removing the medication was responsible for following physician orders, and she acknowledged the risk of leaving a topical medication on longer than ordered included skin irritation. The DON stated nurses were responsible for following physician orders and that there was no monitoring system in place for the patch issue, while also stating the potential risk of not signing the narcotic books per policy included drug diversion.
Medication Cart Not Kept Clean and Free of Loose Medication
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles and failed to keep the 300-hall medication cart clean and free from dried drippings, pieces of paper, and a loose tablet. During an observation of the cart with LVN I, the second drawer contained blister packet medications with pieces of paper from the blister packets and a loose tablet medication on the bottom of the drawer. The observation also found a dried deep-yellow dripping on the first drawer on the right side of the medication cart. In an interview, LVN C stated the nurse or medication aide using the cart for the shift was responsible for keeping it clean and that nursing staff were to clean and maintain the cart every shift. She stated that loose tablets and dried drippings in a medication cart could expose residents' medications to unknown substances causing unknown reactions. The DON stated the pharmacy nurse completed a comprehensive monthly review of the facility's medication carts and reviewed medications and cart cleanliness. The facility policy on Medication Administration stated medications were to be administered in a manner to prevent contamination or infection and to keep the medication cart clean, organized, and stocked with adequate supplies.
Failure to Protect Resident Privacy and Dignity During Glucose Checks and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain privacy, dignity, and confidentiality when performing blood glucose checks and administering insulin to four residents. On a specified date, RN A conducted glucose testing and insulin injections for four male residents in a TV room/common area rather than in a private setting. More than 15 other residents were in close proximity during these procedures, allowing others to see and potentially overhear the residents’ glucose readings, insulin type, and dosage. This occurred despite facility policy stating that residents have a right to personal privacy and confidentiality of their personal and medical records, including during medical treatment. The four residents involved all had diabetes mellitus and varying degrees of cognitive impairment as documented in their MDS assessments and medical records. One resident had a BIMS score of 3 and diagnoses of Alzheimer’s dementia and type 2 diabetes, with a care plan focus on disorientation from dementia and interventions to provide choices and assist with decision making. Another resident had a BIMS score of 6, diagnoses of type 2 diabetes, dementia, and bipolar disorder, and a care plan focus on impaired communication with interventions to allow adequate response time and evaluate comprehension. A third resident had a BIMS score of 4, required daily insulin injections, and had a care plan for diabetes management including monitoring for hypo/hyperglycemia, rotating injection sites, and monitoring food intake. The fourth resident had a BIMS score of 11, required daily insulin, and had care plan interventions addressing cognition, including asking simple questions, not rushing, and explaining procedures, along with diagnoses of hearing loss, type 2 diabetes, and dementia. Interviews with facility leadership confirmed that the observed practice of performing glucose checks and insulin injections in a common area was contrary to expectations and resident rights. The Supervisor RN stated that glucose checks should be done in residents’ rooms to uphold dignity and prevent others from overhearing blood sugar levels, insulin brand, and dosage, and that residents could feel embarrassed if care was provided in the open. The Unit Manager stated that blood sugar readings and insulin injections are treatments that must be completed in residents’ rooms to protect privacy and that all patient-related care should occur in residents’ rooms, including for those on a memory unit. The ADON stated that residents needed to be in their rooms for glucose readings and insulin injections because skin would be exposed and that providing such care in open areas created dignity and HIPAA concerns by disclosing glucose readings, diagnoses, dosages, and insulin types. The Administrator acknowledged that providing treatment in open areas was a privacy concern and that residents’ diagnoses, medications, glucose levels, vitals, and exposed stomachs could be seen by others, conflicting with the facility’s stated practice of providing privacy when residents receive care.
Failure to Follow Hand Hygiene and PPE Protocols During Wound Care and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program, specifically related to hand hygiene and PPE use during wound care and blood glucose monitoring with insulin administration. During wound care for a resident with a sacral pressure injury, an LVN donned a PPE gown without securing the back or neck ties, disposed of the resident’s soiled wound dressing, and continued to clean the wound without performing hand hygiene or changing gloves. The LVN then removed and discarded the gown because it was getting in the way and continued cleaning the wound without a gown. He began to open new dressings to apply to the wound and only performed hand hygiene and changed gloves after being stopped and questioned by the state surveyor. He completed the remainder of the wound care without wearing a PPE gown. The resident receiving this wound care had a documented Stage 4 pressure injury to the sacrum, with orders for daily alginate calcium primary dressing and gauze island secondary dressing, and a care plan directing staff to administer treatments as ordered and monitor for changes in skin status. The LVN later stated he forgot to wash his hands and change gloves after disposing of the dirty dressing and cleaning the wound, and acknowledged he was expected to perform hand hygiene before applying the new dressing. He reported he did not typically provide wound care because the facility had a designated wound care nurse, and that he removed the gown because it was too small and not secured, noting that larger gowns previously provided had run out and that he was supposed to notify the nurse supervisor when PPE supplies were low. The DON stated staff were to don gown and gloves at minimum for wound care, that it was not appropriate to remove the gown during the procedure without reapplying it, and that staff were expected to perform hand hygiene before applying PPE, before beginning wound care, when changing gloves during wound care, and before applying the new dressing. Additional deficiencies were observed in hand hygiene practices during glucose monitoring and insulin administration for four residents with diabetes and varying degrees of cognitive impairment. An RN performed blood glucose checks and insulin injections for multiple residents without sanitizing her hands between glucose measuring and filling the insulin syringe, and in some instances did not sanitize after administering insulin, disposing of sharps, and removing gloves before touching the medication cart and a resident’s door handle. She also proceeded from one resident to another without practicing hand hygiene between residents. In interviews, the RN acknowledged she should sanitize before and after every glove application, admitted she did not adhere to that standard, and attributed her lapses in part to not having hand sanitizer readily accessible on her cart. Other nursing staff, supervisors, the unit manager, ADON, and the DON described the expected procedure for glucose monitoring and insulin administration, consistently stating that there should be multiple (3–4) hand hygiene opportunities during the process, including before and after glove use and between residents, and that staff were responsible for following the facility’s hand hygiene and infection control policies. Facility policies on hand hygiene and infection prevention and control required staff to perform hand hygiene per established procedures and to use PPE according to facility guidelines when providing resident care.
Failure to Immediately Notify NP/MD of New Osteomyelitis Diagnosis After Outside Appointment
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify and consult with a resident’s physician or NP/MD when there was a significant change in the resident’s condition and diagnosis. The resident was an older male with diabetes mellitus with hyperglycemia and a history of open wounds on the left foot and great toe. He had been referred to a podiatrist and then to a local hospital due to concern for osteomyelitis in the left foot, with MRI imaging consistent with left calcaneal osteomyelitis and possible left 5th toe osteomyelitis. Despite this new diagnosis, the facility’s records did not show that the NP/MD was promptly informed of the osteomyelitis. Record review showed a podiatrist progress note indicating erosion of the left 5th toe consistent with osteomyelitis and a plan to consult infectious disease, but there was no corresponding nursing progress note documenting notification to the NP/MD of this new diagnosis. A progress note dated two days later documented that the resident was sent to the hospital for further evaluation regarding osteomyelitis, but the facility’s documentation did not reflect that the NP/MD had been notified when the diagnosis was first identified. The resident’s care plan included IV therapy related to osteomyelitis, with interventions such as administering IV fluids per order, monitoring for infection, and notifying the physician of signs and symptoms of infection or complications, but the initial diagnostic information from the podiatrist visit was not promptly relayed. In interviews, nursing staff and leadership described that the receiving nurse was responsible for reviewing outside provider notes and immediately notifying the NP/MD of any new orders or diagnoses, and then documenting a progress note. LVN staff acknowledged that failure to notify the NP/MD could cause a delay in care and miscommunication, and one LVN stated he only learned of the osteomyelitis diagnosis from the resident’s POA. The NP reported she was not notified by facility nurses about the osteomyelitis diagnosis and instead learned of it from a family member. The DON stated that because the podiatrist’s note contained no new orders and described the condition as stable with a referral to infectious disease, she believed immediate notification of the NP was not necessary and that next-day notification would be acceptable. The facility’s written policy on change in resident condition required licensed nurses to notify the attending physician or designee and resident representative in situations requiring a change in medication or treatment regimen, including new conditions and skin issues, but the osteomyelitis diagnosis was not immediately communicated to the NP/MD as required.
Failure to Accurately Code Osteomyelitis Diagnosis on Discharge MDS
Penalty
Summary
The facility failed to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s active diagnosis of osteomyelitis. The resident, an adult male admitted with a history including an open wound of the foot, open wound of the left great toe, and diabetes mellitus with hyperglycemia, was referred to the hospital due to concern for osteomyelitis of the left foot. Hospital records, including MRI imaging, documented left calcaneal osteomyelitis and possible left 5th toe osteomyelitis, and the resident was admitted for management of a urinary tract infection and a left open wound concerning for osteomyelitis, with a plan for antibiotic therapy prior to return to the facility. Despite this, the resident’s discharge MDS did not include osteomyelitis as a diagnosis, even though the resident’s care plan identified a need for IV therapy related to osteomyelitis and listed interventions such as administering IV fluids per order, auscultating lung sounds, monitoring the IV site for infection, and notifying the physician of signs and symptoms of infection or complications. During interviews, the MDS LVN stated that the MDS assessment is intended to depict the care being provided to the resident and that all active diagnoses should be included. He explained that floor nurses were responsible for updating the MDS upon initiation of a new diagnosis and that he only reviewed the MDS quarterly. He further stated that if a diagnosis was missing from the MDS, he viewed it as a reimbursement issue rather than a risk to resident care and reported that he had not received in-services on accurate MDS completion. The Administrator stated that he primarily focused on the BIMS score and was unsure whether resident diagnoses had to be included in the MDS, acknowledging that omitting medical diagnoses would not show the resident’s full clinical picture. He indicated that floor nurses and MDS nurses were responsible for accurate completion of the MDS and could not recall the last in-service provided. The facility’s Resident Assessment policy stated that a comprehensive assessment would be completed when a significant change was determined based on RAI manual criteria, but the osteomyelitis diagnosis was not reflected on the resident’s discharge MDS.
Failure to Document NP/MD Notification of Osteomyelitis Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident with a diagnosis of osteomyelitis. The resident, an older male with diabetes mellitus with hyperglycemia and open wounds of the left foot and great toe, had been admitted to the facility in February 2025 and discharged in January 2026. Hospital records from February 2025 documented concern for and MRI-confirmed calcaneal osteomyelitis of the left foot and possible osteomyelitis of the left 5th toe, with a plan for antibiotic therapy. The resident’s discharge MDS showed moderately impaired cognitive skills for daily decision-making, indicating the resident required cues or supervision. On December 9, 2025, a facility progress note documented that the resident had a podiatry appointment. A podiatrist’s progress note (undated in the record) later indicated erosion of the left 5th toe consistent with osteomyelitis and stated that infectious disease would be consulted that day, noting the toe was stable. However, the facility’s progress notes dated December 10, 2025 contained no documentation of the podiatrist’s osteomyelitis diagnosis and no record that the NP/MD was notified of this diagnosis. A subsequent progress note dated December 12, 2025 documented that the resident was sent to the hospital for further evaluation of osteomyelitis because the VA infectious disease appointment was taking too long to schedule. Interviews with staff confirmed that facility practice and expectations required nurses to review outside provider notes, notify the NP/MD immediately of any new orders or diagnoses, and document this notification in a progress note. LVN A stated that the nurse receiving the resident from an outside appointment and whoever reviewed the progress note were responsible for informing the NP and documenting the notification, and that failure to do so could result in delay in care and miscommunication. LVN B reported he was not aware of the osteomyelitis diagnosis until informed by the resident’s POA on December 12, 2025 and acknowledged that nurses were expected to notify the NP immediately of changes and document this, though he did not always document a note if there were no new orders. The DON stated that, in this case, she did not believe immediate NP notification was necessary because the podiatrist’s note contained no new orders and described the condition as stable, and she considered next-day notification acceptable. The Administrator, however, stated that staff were to notify the nursing supervisor and NP immediately of any new orders or changes in diagnosis and document a progress note. Review of the facility’s October 2021 “Medical Record Documentation” policy showed that licensed staff and interdisciplinary team members were required to document observations and services provided in the resident’s medical record in accordance with state law. The absence of documentation of NP/MD notification of the osteomyelitis diagnosis on December 10, 2025 constituted the cited deficiency.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency as required. Specifically, when a resident alleged that an LVN squeezed her left hand, resulting in bruising, the facility did not report this allegation to the State Survey Agency within the mandated two-hour timeframe. The incident was documented by staff, and the resident demonstrated and described the alleged abuse, with staff noting that the bruises appeared consistent with fingerprints. Despite this, the facility did not treat the allegation as reportable abuse at the time. The resident involved had a complex medical history, including venous insufficiency, generalized anxiety disorder, delusional disorders, muscle wasting and atrophy, muscle weakness, and heart failure. She was noted to have aggressive behaviors, including attempts to hit staff, verbal aggression, and refusal of care and medications. On the day of the incident, staff observed multiple bruises on her left hand, and the resident reported pain and described her hand being squeezed by a nurse. Staff notified supervisors and the DON, and an x-ray was ordered, but the incident was not reported to the State Survey Agency as an abuse allegation within the required timeframe. Interviews with staff revealed confusion and disagreement about whether the incident constituted abuse and whether it should have been reported. The DON and Administrator reviewed the situation and determined, based on documentation of the resident's combative behavior, that the bruising could be explained by the resident's actions rather than abuse. As a result, the alleged perpetrator was not suspended, and the incident was not reported as required by facility policy and regulation. The facility's own policies require immediate reporting of all abuse allegations, but this process was not followed in this case.
Failure to Complete Required Annual Employee Registry Screenings
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation by not completing required annual employee misconduct registry (EMR) and nurse aide registry (NAR) screenings for two certified nurse aides (CNAs). According to the facility's policy, EMR and NAR screenings must be conducted upon hire and annually for all employees, including contracted staff, students, volunteers, and consultants, with documentation maintained as proof. Record reviews and interviews revealed that CNA A, hired on 03/26/24, had only one EMR/NAR screening completed on 03/20/2024, with no evidence of an annual screening in the employee file. Similarly, CNA B, hired on 05/01/18, had the last EMR/NAR screening on 01/31/24, with no documentation of an annual screening as required. Interviews with the HR Resource Assistant and HR Business Partner confirmed that annual EMR/NAR screenings had not been completed for CNA A and CNA B, and that such checks should be performed upon hire and annually according to facility policy. The Administrator also acknowledged that the screenings were not completed as required. This failure to follow established screening procedures could place residents at risk for abuse, neglect, exploitation, and misappropriation of property, as the facility did not ensure ongoing verification of employee eligibility and background in accordance with its own policies.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that residents received adequate supervision to prevent accidents for two residents reviewed for quality of care. For one resident with severe cognitive impairment, right-sided hemiparesis, and a history of falls, the call light was not within reach, assist bars were not in place, and the bedside table was positioned away from the resident. This resident required maximal assistance for bed mobility and had documented interventions for fall risk, including the use of assistive devices and call light placement. On the day of the incident, the resident was found on the floor after an unwitnessed fall from bed, with subsequent pain and abrasions, and was sent to the hospital for evaluation. Observations and interviews confirmed that the call light was not accessible and the bedside table was not appropriately positioned, contrary to the care plan and facility policy. Another resident, who was cognitively intact but required substantial assistance for bed mobility due to morbid obesity, osteoarthritis, and COPD, did not have a PT/OT evaluation completed for the use of assist bars after new beds were installed. This resident had previously used bed rails to assist with mobility and reported a loss of independence after their removal. The facility had not completed the required side rail assessment or therapy evaluation to determine the need for assist bars, resulting in the resident waiting for staff assistance for bed mobility. Interviews with staff and the resident confirmed that the lack of assist bars affected the resident's ability to move independently in bed. Facility staff interviews revealed that the process for evaluating and installing assist bars was delayed due to the arrival of new beds and pending therapy assessments. Maintenance staff were waiting for therapy's list before installing assist bars, and clinical leadership acknowledged that therapy evaluations were progressing slowly. The facility's policies required individualized assessments and interventions for fall prevention and side rail use, but these were not consistently implemented for the affected residents, leading to unmet care needs and increased risk for accidents.
Failure to Ensure Nursing Staff Competency in Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide safe and appropriate care to residents, as evidenced by two specific incidents involving a registered nurse (RN). In the first incident, the RN delegated the task of checking a resident's blood glucose level to a certified nurse aide (CNA), despite facility policy and in-service training explicitly prohibiting CNAs from performing this task. The RN, who had prior experience in an acute hospital setting where CNAs were permitted to check blood sugars, was unaware of the restriction in the long-term care setting. The CNA, also previously employed in a hospital, was similarly unaware of the policy. The blood glucose check was performed by the CNA, and the RN subsequently administered insulin based on the result provided by the CNA. In the second incident, the same RN administered an insulin injection to another resident in the main dining room by injecting through the resident's shirt without cleaning the injection site. The RN admitted to this practice, stating that he was rushing and did not want to roll up the resident's sleeve in the dining room. The RN acknowledged that this was not in accordance with his training and recognized that the injection site should have been cleaned prior to administration. The incident was observed and reported by a restorative CNA, who noted that the resident was startled by the injection and that the site was not cleaned before the injection was given. Interviews and record reviews revealed that the facility did not have a skills checklist specific to insulin administration for licensed staff at the time of the incidents. Additionally, there was a lack of written documentation regarding the investigation and re-education of staff involved in these incidents. The facility's policy on medication administration required medications to be administered as ordered and in accordance with manufacturer specifications, which include proper site selection and cleaning prior to injection. The events described demonstrate that the RN did not follow established facility policies and procedures in both delegating tasks and administering injections.
Failure to Administer Insulin According to Physician Orders and Manufacturer Guidelines
Penalty
Summary
A deficiency occurred when a resident with a history of dementia and type 2 diabetes did not receive insulin according to physician orders. The resident was admitted with orders for blood glucose checks before meals and administration of sliding scale insulin based on those results. On one occasion, the assigned LVN failed to check the resident's blood glucose before dinner and, as a result, did not administer the prescribed insulin. The LVN later stated that she was occupied with a medical emergency involving another resident and was unable to perform the required blood glucose check and insulin administration as ordered. On a separate occasion, the same LVN administered rapid-acting insulin to the resident well before the scheduled dinner time, and the resident did not receive a meal or snack within the recommended timeframe after insulin administration. The insulin was given at approximately 4:08 p.m., but the resident did not receive his dinner tray until about 5:15 p.m., exceeding the recommended interval for providing food after rapid-acting insulin. Facility policy and manufacturer specifications require that a meal or substantial snack be provided within 15 minutes of administering rapid-acting insulin to prevent hypoglycemia. Observations and interviews confirmed that the resident was non-verbal, had significant cognitive impairment, and required assistance with feeding. Staff interviews revealed inconsistent knowledge and practices regarding the timing of blood glucose checks and insulin administration relative to meals. Documentation showed that the required procedures were not followed, resulting in significant medication errors for the resident.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that all alleged violations involving misappropriation of resident property were reported to the State Survey Agency as required. Specifically, a male resident with intact cognition reported his wallet, containing identification documents, a Social Security card, a checkbook, and approximately $180, as missing. The initial report of missing items was documented, and some items were found and returned. However, when the wallet and additional items were reported missing again, the facility did not report the incident to the State Survey Agency, despite the policy requiring such reporting for all allegations of misappropriation. The investigation included interviews with the resident, his spouse (who was also a resident and had severe cognitive impairment), and staff. The resident suspected his spouse, who had a history of wandering and confusion, may have taken the wallet without consent, but she was unable to recall or communicate about the incident. Staff and the social worker conducted searches of the resident's room, the spouse's new room in memory care, the laundry, and common areas, but the wallet was not located. The resident monitored his financial accounts and canceled his cards, reporting no unauthorized activity. The administrator acknowledged awareness of the requirement to report missing items to State Operations but determined that, in this case, the lack of a clearly identified perpetrator and the possibility of the wallet being misplaced rather than deliberately taken did not meet the threshold for misappropriation. The facility's policy defined misappropriation as the deliberate misplacement or wrongful use of a resident's belongings without consent and required immediate investigation and reporting of such allegations. Despite this, the incident was not reported to the State Survey Agency as required by policy.
Failure to Serve Meals Simultaneously in Memory Care Unit
Penalty
Summary
The facility failed to treat residents with respect and dignity by not serving meals simultaneously to all residents at the same table in the memory care unit. During an observation, it was noted that residents had to wait up to 30 minutes for their meals while their tablemates were already eating. This discrepancy in meal service was observed across multiple tables, affecting 7 out of 15 residents reviewed for residents' rights. The delay in serving meals led to situations where some residents had consumed a significant portion of their meals while others at the same table had not yet been served. Interviews with the Director of Nursing (DON), a Pharmacy Nurse, and the Interim Certified Dietary Manager (CDM) revealed that the responsibility for ensuring simultaneous meal service lies with the nursing and kitchen staff. The DON acknowledged the unfairness of the situation and emphasized the need for nursing staff to notify the kitchen about pending trays. The Pharmacy Nurse and Interim CDM confirmed that the nursing staff, with assistance from administrative staff, are responsible for passing trays and ensuring all residents at a table are served together. The facility's policy on resident rights underscores the importance of treating residents with respect and dignity, which was not upheld in this instance.
Deficiency in Resident Grievance Process Awareness
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process, as evidenced by interviews and record reviews. During a Resident Council meeting, five out of twelve residents reported not knowing how to file a grievance or who was responsible for handling grievances. The residents stated that they had not been informed about the grievance process during their admission, and the Resident Council Minutes from August 2024 to January 2025 showed no discussion of grievance policies or resident rights. Interviews with facility staff, including the Activities Director, Social Worker, LVN, Director of Admissions, DON, and Administrator, revealed inconsistencies in the communication and education of the grievance process to residents. The Activities Director admitted to not recording discussions about filing grievances in the meeting minutes, and the Social Worker acknowledged a lack of records on assisting residents with grievances. The Director of Admissions and LVN expressed uncertainty about how residents were informed of the grievance process, while the DON and Administrator recognized the need for improvement in educating residents on filing grievances. The facility's policy on Resident Rights, dated February 2020, states that residents should be notified of their right to file grievances both orally and in writing, with contact information for independent entities provided. However, the report indicates that this policy was not effectively communicated to residents, leading to a deficiency in ensuring residents' awareness of the grievance process.
Failure to Post Oxygen Signs in Resident Rooms
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents who required oxygen therapy, as observed by the absence of oxygen signs outside their rooms. Resident #68, an elderly male with a history of dementia, pulmonary embolism, and other respiratory conditions, was using oxygen in his room without a sign posted outside. Similarly, Resident #142, an elderly female with severe cognitive impairment and multiple health issues, also had an oxygen concentrator in her room without the required signage. Interviews with various staff members, including LVNs, CNAs, the RN Supervisor, the Activities Director, and the DON, confirmed that the facility's policy required oxygen signs to be posted outside rooms where oxygen concentrators were in use. The absence of these signs was acknowledged by the staff, who recognized the potential risks, including unchecked oxygen levels and fire hazards, particularly in the case of Resident #68, who was noted to be a smoker. The facility's Oxygen Administration Policy, dated February 2015, mandates the placement of non-smoking signs outside residents' rooms to prevent fire hazards and ensure proper monitoring of oxygen levels. Despite this policy, the deficiency was observed, indicating a lapse in adherence to established safety protocols, as confirmed by the facility's staff and administration during interviews.
Deficiencies in Pharmaceutical Services and Record-Keeping
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by several deficiencies in medication administration and record-keeping. Specifically, the facility did not ensure that licensed staff signed the Controlled Drugs-Audit Record form after counting and verifying all controlled substances in the medication cart during shift changes. Additionally, a licensed staff member failed to update the individual control drug record after administering controlled medication to a resident, resulting in an inaccurate count of medication. This discrepancy was observed when the remaining amount of Tramadol in the blister packet did not match the count on the control drug record. Furthermore, the facility did not ensure that the temperature log for vaccines and medications was signed after verifying the correct refrigerator temperature. This lapse in procedure was noted in the medication room, where the temperature log was not signed for the morning shift. These failures in documentation and procedure could potentially place residents at risk for not receiving the intended therapeutic response of prescribed medications and increase the risk of drug diversion of controlled substances.
Medication Storage Deficiency Due to Unclean Bottles
Penalty
Summary
The facility failed to ensure the proper storage and cleanliness of medication and treatment carts, which was observed during a survey. Specifically, liquid medications stored in medication carts on three different halls (300, 700, and 800) were found with dried drippings on the sides of the bottles. This included bottles of ProStat and Valproic acid. Additionally, a treatment cart contained a bottle of povidone iodine with similar dried drippings. Interviews with the Licensed Vocational Nurses (LVNs) responsible for these carts revealed that they were trained to keep medication bottles clean to prevent cross-contamination, yet the bottles were not maintained as such. The Director of Nursing (DON) confirmed that nurses were trained to keep medication carts clean and to store medications by route, with liquid bottles kept clean and upright. However, the facility's policy and procedure on Storage and Expiration Dating of Medications and Biologicals did not provide specific instructions on maintaining bottles free of dried drippings. The presence of dirty bottles in the medication carts posed a potential risk for bacterial contamination, which could affect residents receiving medications at the facility.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to provide meals at an appetizing and safe temperature during a lunch service, as observed on January 28, 2025. The deficiency was noted for pureed, regular, and mechanical soft meals, specifically involving fried zucchini and Albondiga (meatball) soup, which were served below the acceptable hot food temperature of 135°F. The pureed diet items were recorded at 131°F and 131.2°F, while the regular diet fried zucchini was at 123°F, and the mechanical soft diet fried zucchini was at 126.1°F. This failure was identified during an observation and interview with the CDM Interim, who acknowledged the temperature readings and the facility's policy requiring hot foods to be served at 135°F or higher. The CDM Interim admitted to forgetting the thermometer and alcohol swabs needed for accurate temperature readings and sanitation during the sampling process. He noted that the food had been in the cart for approximately 15 minutes, which contributed to the temperature drop. Despite the facility's policy on food holding and service, the CDM Interim expressed concern about the potential risks of serving food below the required temperature, including the possibility of foodborne illnesses such as salmonella. The facility's policy, dated October 2018, mandates that all hot foods be served at a temperature of 135°F or greater, highlighting a lapse in adherence to this standard during the observed meal service.
Inaccessible Call Light Poses Risk to Resident
Penalty
Summary
The facility failed to ensure that resident call lights were kept within reach, which resulted in a deficiency for one resident. During an observation, it was noted that the call light for a resident was tangled and lying on the floor, making it inaccessible. The resident confirmed that she could not reach the call light and would have to wait for a staff member to pass by to call for help. Interviews with various staff members, including CNAs, an RN, the Activities Director, an LVN, the DON, and the Administrator, revealed that all were aware of the policy requiring call lights to be within reach of residents. However, the policy was not adhered to in this instance. The resident involved was an elderly female with multiple health conditions, including generalized muscle weakness, coronary artery disease, hypertension, renal insufficiency, and obstructive uropathy. Her care plan specifically indicated that the call light should be within reach when she was in bed due to her risk of falls. Despite this, the call light was not accessible, posing a risk of unmet needs. The facility's policy, dated October 2019, stated that call lights should be functional and within reach to allow residents to call for assistance, but this was not followed in the case of the resident.
Incomplete Documentation of Behavioral Incidents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, which could potentially place them at risk of not receiving needed services or errors in treatment. For one resident, the facility did not document a behavioral incident in the Medication Administration Record/Treatment Administration Record (MAR/TAR) where the resident exhibited irritability and aggression by pulling a roommate's blanket and slapping the roommate. This incident was not recorded in the MAR/TAR despite being tracked for such behaviors every shift. Similarly, another resident's behavioral incident was not documented in the MAR/TAR. This resident hit another resident on the leg with a walker, an incident that was also supposed to be tracked for aggressive behavior related to delusional and impulse disorders. The Director of Nursing (DON) acknowledged that the MAR/TAR is used for making decisions regarding resident care planning and that the incidents should have been documented accurately. The facility's policy requires that documentation be completed at the time of service or no later than the shift in which the observation occurred.
Failure to Prevent UTI Due to Improper Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with a catheter. The resident, an elderly male with obstructive and reflux uropathy and benign prostatic hyperplasia, was observed with his catheter drainage collection bag lying on the floor. This observation was made by a Health and Human Services Investigator, and it was noted that the resident was asleep at the time. The facility's care plan for the resident included keeping the Foley bag off the floor, but this was not adhered to. Interviews with facility staff, including an LVN, ADON, and DON, revealed that the drainage bag should have been attached to the bedframe below the resident's bladder level to prevent infection and possible spills. The LVN acknowledged that the CNAs had recently changed the resident but failed to reattach the drainage bag properly. The ADON and DON confirmed that it was the responsibility of the nursing staff, including CNAs, to ensure the drainage bag was off the floor. The facility's catheter care policy emphasized maintaining proper technique to prevent infections, but this was not followed in this instance.
Failure to Post Oxygen Use Sign for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen management, as observed during a survey. The resident, an elderly male with a history of acute upper respiratory infection and obstructive sleep apnea, was admitted to the facility and had an order for oxygen therapy at 2-3 liters per nasal cannula as needed for shortness of breath or comfort. Despite the care plan indicating the need for a 'No Smoking' sign on the resident's door while oxygen was in use, no such sign was present during the observation. The Assistant Director of Nursing (ADON) acknowledged the absence of the required 'Oxygen in Use' sign, which was a responsibility shared with the floor nurse. The ADON admitted to not knowing why the sign was missing and noted that the purpose of the sign was to inform others of the oxygen use in the room. The facility's Oxygen Therapy policy, dated 2012, also required the placement of such signs. The lack of signage could potentially lead to an unsafe environment, although the ADON considered the risk minimal due to the facility's smoke-free status.
Failure to Document PRN Oxygen Order
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding a physician's order for PRN oxygen. The resident, an elderly male with acute upper respiratory infection and obstructive sleep apnea, was admitted to the facility and required oxygen therapy. On a specific date, the resident's oxygen levels dropped, prompting a nurse to administer oxygen and notify the RN Supervisor. However, the nurse did not document the physician's order for PRN oxygen in the system, which was a requirement according to the facility's policy. The Director of Nursing (DON) confirmed the absence of the order in the system and acknowledged that the nurse was busy stabilizing the resident and forgot to enter the order. The Nurse Practitioner (NP) had given a verbal order for PRN oxygen, but it was not documented by the nursing staff. This oversight could have led to treatment errors, as other staff members might not have been aware of the resident's need for oxygen. Despite the documentation failure, the resident received continuous oxygen, and there was no negative outcome reported.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care. Resident #8's quarterly MDS assessment did not account for his g-tube status, despite his care plan indicating a need for feeding related to dysphagia. The Unit Manager confirmed that Resident #8 had a g-tube since admission, and the MDS Nurse acknowledged the oversight. This inaccuracy could affect the resident's nutritional and hydration status management. Similarly, Resident #16's quarterly MDS assessment did not reflect his behavior of making false accusations, even though his care plan noted repeated criticism of staff. The Unit Manager and MDS Nurse both confirmed awareness of these behaviors, yet the MDS assessment failed to include them. This omission could impact the staff's ability to manage and document the resident's behavioral issues effectively. Both inaccuracies were attributed to errors in the MDS assessments, which are reviewed quarterly, annually, and yearly by the MDS Nurses.
Failure to Implement Care Plan for Resident's Behavior
Penalty
Summary
The facility failed to implement care interventions in accordance with the written plan of care for a resident who exhibited behavior of pulling on a drainage tube. Despite the resident's history of pulling on the drainage tube, this behavior was not addressed in the care plan. The resident, who was cognitively intact with a BIMS score of 11, had multiple incidents of pulling on the drainage tube, which led to the tube being dislodged and required medical intervention. The staff, including CNAs and LVNs, were aware of the behavior and took measures such as frequent rounding, moving the resident closer to the nurse's station, and involving the family in monitoring. However, these interventions were not documented in the care plan. Interviews with staff revealed that the MDS nurse responsible for the resident's care plan was not aware of the behavior, despite it being discussed in daily morning meetings. The Unit Manager acknowledged that the behavior should have been included in the care plan to ensure proper monitoring. The facility's policy on care plans emphasizes the need to develop comprehensive, person-centered care plans that identify care needs and include individualized approaches. The failure to document and implement the behavior-focused interventions in the care plan represents a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not immediately suspend CNA B after CNA A reported suspected roughness when CNA B was providing care to a resident. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. The resident involved was an elderly female with diagnoses of dementia, Alzheimer's, acute pain due to trauma, and anxiety. Her cognitive level was severely impaired, and she exhibited behavior symptoms like verbal/vocal symptoms such as screaming and disruptive sounds. On the day of the incident, CNA A reported that CNA B had grabbed the resident by her arms and pulled her strongly towards her. Despite this report, CNA B was allowed to continue working her shift and was only suspended after her shift ended. Interviews with the DON, Administrator, and other staff revealed inconsistencies in the handling of the incident. The DON and Administrator began investigating around lunchtime, gathering statements from staff, but did not immediately suspend CNA B. The facility's policy required immediate suspension of the alleged perpetrator pending investigation, but this was not followed. The investigation results were deemed unsubstantiated due to inconsistencies in CNA A's statements and lack of physical or emotional distress observed in the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Patriot | 2.6 mi | — | 19 | 1 |
| Los Arcos Del Norte Care Center | 3.1 mi | — | 0 | 0 |
| The Montevista At Coronado | 5.8 mi | — | 0 | 0 |
| Mountain Villa Nursing Center | 6.1 mi | — | 27 | 0 |
| Nazareth Living Care Center | 7 mi | — | 6 | 0 |
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