Ballinger Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ballinger, Texas.
- Location
- 2001 6th St, Ballinger, Texas 76821
- CMS Provider Number
- 675614
- Inspections on file
- 24
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Ballinger Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of hip fracture, stroke, dementia, osteoporosis, severe cognitive impairment, and dependence for transfers was observed being transferred by two CNAs who, despite applying a gait belt, hooked their arms under the resident’s arms and one also grabbed the seat of the resident’s pants during a pivot transfer. The DOR stated this method did not meet the facility’s expectations for a two-person gait belt transfer, which required both staff to control the resident using the gait belt only, and confirmed that hooking under the arms or using the seat of the pants was not appropriate. Facility in-service materials and written policy directed staff to use a gait belt and, when two staff were needed, to grasp the gait belt on each side to safely stand and turn the resident, but this procedure was not followed during the observed event.
The facility did not have a qualified full-time DON or an eligible interim DON for an extended period after the previous DON left. The Administrator reported that an RNC was overseeing nursing services and was available by phone, but acknowledged that the RNC did not meet DON requirements because they were not present in the facility 8 hours a day. The facility also lacked a written policy for DON requirements and relied on state regulations for guidance, and the Administrator believed there had been no negative resident outcomes during this time.
The facility failed to post required oxygen-in-use signage outside the rooms of two residents receiving oxygen therapy via nasal cannula. Both residents had documented diagnoses requiring oxygen, active care plans referencing oxygen therapy, and physician orders for oxygen at 2–5 L/min PRN or 2 L/min every shift, with observations confirming oxygen concentrators in use. Despite this, no oxygen signs were posted on their doors, contrary to facility policy and the stated expectations of the ADON and Administrator that such signage be used for safety and no-smoking precautions.
Surveyors identified that three dual-occupancy rooms lacked full visual privacy because the central ceiling-to-floor curtains stopped short of the wall and the side curtains for each bed left significant gaps, preventing complete separation between roommates. An interview with the Administrator confirmed that rooms without full visual privacy curtains could not provide privacy when requested and that there was no existing policy addressing privacy curtains.
A resident with a g-tube and multiple comorbidities did not receive g-tube medications according to professional standards or facility policy when the ADON administered crushed medications using excessive water volumes, failed to perform hand hygiene before care, and did not change visibly soiled gloves. The ADON placed a syringe plunger on an unclean bedside surface outside the clean field and reused it without cleaning, and did not fully dissolve certain medications, discarding undissolved portions so the resident did not receive full ordered doses. Facility policies required hand hygiene before resident contact and limited water flushes to 5–15 ml between medications, and the RNC later acknowledged expectations for proper infection control and g-tube procedures but could not locate specific g-tube medication training for staff.
A resident with dementia and CHF, care planned and assessed for oxygen therapy, had an order for PRN oxygen at 2–5 LPM via nasal cannula for SOB. Review of the resident’s January eTAR showed that nursing staff did not document oxygen administration, including oxygen use, pulse, respiratory rate, and time completed, on the eTAR, even though some information was recorded only in the vital signs section. The ADON and Administrator both stated that treatments were expected to be documented on the eTAR, and the facility’s documentation policy required complete and accurate documentation on all appropriate clinical record sheets.
A resident with an uninhibited neuropathic bladder, colostomy, and indwelling Foley catheter was care-planned for Enhanced Barrier Precautions (EBP), requiring gown and gloves for high-contact care such as catheter care. During an observed catheter change, an LVN performed hand hygiene and wore gloves but did not don a gown, despite EBP signage outside the room and gowns available in the room. The LVN later acknowledged she had been trained on EBP, knew a gown was required, and stated she forgot due to being distracted. The ADON and Administrator confirmed staff were expected to use appropriate PPE for this resident’s catheter care and that failure to do so could spread infections.
The facility failed to follow professional standards for food safety and infection control. Chicken was improperly thawed, and a staff member wore a face mask incorrectly while preparing food. Food storage was inadequate, with exposed chicken and dry milk on the floor. Hair restraint practices were not followed, and thermometer cleaning was insufficient, leading to cross-contamination. The facility's policies on thawing, storage, and infection control were not adhered to.
A nurse in an LTC facility failed to perform hand hygiene between glove changes during medication administration and wound care for two residents, leading to potential infection control issues. The nurse placed wound care supplies on a porous towel on the floor and did not adhere to the facility's infection control policies, which require hand hygiene and the use of non-porous barriers.
A nurse's treatment cart on Hall 4 was left unlocked and unsupervised for about 10 minutes, containing ointments, nail clippers, dressings, and saline bottles. RN A was unaware of leaving the cart unlocked while attending to a resident. The DON and Administrator confirmed the expectation for carts to be locked to prevent unauthorized access, as per facility policy.
Improper Two-Person Transfer Technique and Failure to Follow Gait Belt Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate supervision and proper assistance devices during transfers, resulting in an unsafe transfer technique by two CNAs. The resident was an elderly female with a history of left hip fracture, stroke, dementia with agitation, osteoporosis, severe cognitive impairment (BIMS score 1/15), signs of delirium, and a pattern of rejecting care on some days. Her MDS and care plan documented that she was dependent on staff for chair-to-bed transfers and required two staff for bed mobility. During an observed transfer from bed, CNA A and CNA B assisted the resident to sit at the edge of the bed, placed a gait belt, and then each CNA hooked her arms under the resident’s arms; CNA A additionally grabbed the seat of the resident’s pants and CNA B grabbed the back of the gait belt before performing a pivot transfer. The Director of Rehabilitation (DOR) stated that the facility’s expectation for a two-person gait belt transfer was for the resident to be positioned between the two staff, with both staff using their hands on the gait belt to assist the resident to stand and control movement, and that hooking arms under a resident’s arms was not appropriate. The DOR described the resident as impulsive following a prior stroke, cognitively impaired with rapid onset of sundowning, and physically fragile due to weight loss, though still able to bear weight, stand, transfer, and walk short distances with encouragement but with poor balance. CNA A later stated she usually transferred residents by the seat of their pants, and the DOR indicated this was not a safe practice. CNA B initially denied but then admitted hooking her arms under the resident’s arms and acknowledged it was not the correct way to transfer. Facility in-service training and written policy on transfers specified the use of a gait belt and, when two staff were required, both were to grasp the gait belt to stand and turn the resident, which was not followed during the observed transfer.
Failure to Maintain a Qualified Full-Time DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the full-time Director of Nursing (DON) and did not have a qualified full-time or interim DON from 12/27/2025 through 02/19/2026. Interview and record review showed that the previous DON’s last day was 12/27/2025, and the Administrator reported that an RNC was acting as the interim DON, overseeing the facility and being readily available by phone as needed. However, the Administrator acknowledged that the RNC did not qualify as an interim DON because the RNC was not in the facility 8 hours a day, as required. The Administrator also stated that the facility did not have a policy outlining DON requirements and instead relied on state regulations for guidance, and believed residents had not experienced negative outcomes because the RNC had been overseeing the facility and nursing staff were available. The surveyors determined that this failure could place all residents at risk of not receiving necessary care and services. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency was identified at the facility level based on staffing and leadership requirements for nursing services.
Failure to Post Oxygen-in-Use Signage for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards by not posting required oxygen signage outside the rooms of two residents receiving oxygen therapy. One resident with dementia and heart failure had a care plan indicating oxygen therapy related to shortness of breath due to congestive heart failure, and an MDS assessment and physician order for oxygen via nasal cannula at 2–5 L/min PRN for shortness of breath. During observation, this resident was in bed with oxygen in use via nasal cannula connected to a concentrator set at 2 L/min, and there was no oxygen sign posted outside the room, despite facility policy requiring a “No smoking – Oxygen in use” sign on the patient’s door when appropriate. Another resident with chronic respiratory failure with hypoxia had a care plan indicating oxygen therapy related to chronic respiratory failure, an MDS assessment documenting oxygen therapy, and a physician order for oxygen at 2 L/min via nasal cannula every shift. Observation showed this resident in bed with oxygen in use via nasal cannula connected to a concentrator set at 2 L/min, again without an oxygen sign posted outside the room. In interviews, the ADON and the Administrator both stated that it was the facility’s expectation that oxygen signs be posted outside rooms where oxygen was being used for safety reasons, including to prevent smoking in those rooms. The facility’s written policy on nasal cannula oxygen therapy also directed staff to post a “No smoking – Oxygen in use” sign on the patient’s door when appropriate.
Failure to Provide Full Visual Privacy in Dual-Occupancy Rooms
Penalty
Summary
Surveyors found that the facility failed to ensure full visual privacy in three dual-occupancy rooms (Rooms 5, 18, and 21) during a review of 30 such rooms. Observations showed that each of these rooms had an A and B bed separated by a single ceiling-to-floor curtain that divided the center of the room but stopped approximately 12 inches from the wall, leaving a gap. In addition, each bed had its own side curtain, but these side curtains left gaps of approximately 18 inches and 30 inches, preventing total visual privacy for the residents in those beds. During an interview, the Administrator acknowledged that if a resident room did not have a full visual privacy curtain, it would not provide privacy when a resident requested it, and also stated that the facility did not have a policy regarding privacy curtains. The report states that this failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being.
Improper G-Tube Medication Administration and Infection Control by ADON
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services provided via gastrostomy tube (g-tube) were delivered according to professional standards and facility policy for one resident. The resident was an elderly female with a g-tube for nutrition, hydration, and medications, and had multiple diagnoses including cerebral palsy, anxiety disorder, intellectual disability, convulsions, and dementia. Her MDS showed severely impaired cognition and total dependence on staff for all ADLs, and her care plan identified a surgical abdominal site related to peg-tube placement with a goal to remain free from infection. Physician orders specified continuous enteral feeding with a defined formula and rate, free water at a prescribed rate and duration, and multiple medications to be administered via the g-tube. During an observed medication administration via g-tube, the ADON began care by donning gloves without performing hand hygiene, contrary to the facility’s infection control policy that requires hand hygiene before direct resident contact and before assisting with meals. The ADON prepared the medications by separating and crushing them, then attached a 60 cc syringe to the g-tube, checked placement, and instilled 60 cc of water before giving medications. She then used more than 30 cc of water for each medication, exceeding the facility’s enteral tube medication administration policy, which directs staff to flush the tube with only 5–15 ml of water after each medication. During the process, the resident coughed, causing medication to spill from the syringe and spatter around the resident. In response to the spatter, the ADON used the syringe plunger to cover the syringe, placed the plunger on an unclean part of the bedside table outside the established clean field, and then reused the plunger without cleaning it. Her gloves became visibly soiled with medication, yet she did not remove them, perform hand hygiene, or change gloves before continuing care. Additionally, the ADON did not fully dissolve certain medications (Dilantin chewable and omeprazole magnesium), leaving a significant amount of medication residue in the cups, which she discarded into the trash. As a result, the resident did not receive the full doses of all ordered medications. In interviews, the ADON acknowledged she should have washed her hands and changed gloves and stated she had not received facility training on g-tube medication administration, while the RNC confirmed expectations for hand hygiene and adherence to g-tube procedures and reported he could not locate any facility training or in-services specific to g-tube medication administration.
Incomplete eTAR Documentation for PRN Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving PRN oxygen therapy. The resident, an older adult admitted with dementia and heart failure, had a care plan indicating oxygen therapy related to shortness of breath due to CHF, with interventions including reassurance, assistance via call system, and staying with the resident during episodes of respiratory distress. The resident’s MDS assessment documented oxygen therapy under Section O for special treatments and procedures. However, review of the resident’s eTAR for January 2026 showed an order for oxygen at 2–5 LPM via nasal cannula as needed for shortness of breath, but the eTAR lacked documentation of oxygen administration, including oxygen use, pulse, respiratory rate, and time completed. During interviews, the ADON stated that nurses were expected to document the resident’s oxygen status on the eTAR and not solely in the vital signs section, explaining that without eTAR documentation they would not know if the resident was using oxygen more regularly or needed it more than PRN. The Administrator confirmed that nursing staff were expected to document residents’ treatments on the corresponding eTAR and acknowledged that, in this case, documentation was present only under vital signs and not on the eTAR. The Administrator further stated that if a treatment was not documented, they would not be able to determine if the treatment was completed. The facility’s documentation policy stated that the facility would maintain complete and accurate documentation for each resident on all appropriate clinical record sheets, which was not followed in this instance.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper implementation of its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for a resident with an indwelling urinary catheter and colostomy. The resident, admitted with an uninhibited neuropathic bladder and identified on the care plan as requiring EBP due to the presence of a colostomy and Foley catheter, had care instructions stating that gloves and a gown should be donned for high-contact activities such as linen changes, resident hygiene, and catheter care. Facility policy on EBP, as well as signage posted outside the resident’s room, directed staff to perform hand hygiene and wear both gown and gloves during high-contact care for residents with indwelling medical devices, including urinary catheters. On the observed date and time, an LVN entered the resident’s room to change the urinary catheter, performed hand hygiene, and donned gloves but did not put on a gown, despite gowns being readily available in a nearby plastic dresser and the posted EBP instructions outside the room. The LVN later acknowledged in an interview that she was supposed to use a gown when changing the catheter, stated she had been trained on EBP, and attributed the omission to being distracted. She also stated that not wearing a gown could lead to infection or cross contamination. The ADON and the Administrator both confirmed that the expectation was for nursing staff to use appropriate PPE, including EBP, when providing catheter care to this resident and that failure to do so could spread infections to and from the resident.
Deficiencies in Food Safety and Infection Control Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. A bag of chicken was found thawing on the counter without running water, contrary to the facility's policy that requires thawing under running water or in a refrigerator. Additionally, a puddle of pink chicken juices was observed, indicating improper handling. A staff member, [NAME] B, was seen wearing a face mask incorrectly and coughing while preparing food, raising concerns about infection control. Further observations revealed that food storage practices were inadequate. A box of chicken was found with exposed chicken in the freezer, and a 50-pound bag of dry milk was left on the floor in the dry storage area. Spices were left open to the air, and the Dietary Manager (DM) admitted that they were not properly closed or wiped off after use. Hair restraint practices were also lacking, as a staff member's hair net was not fully covering her hair, and another staff member entered the kitchen without a hair net on. The facility's thermometer cleaning practices were also deficient. A staff member, [NAME] C, used a paper towel to clean the thermometer between dishes, which she acknowledged caused cross-contamination. The DM admitted to not addressing these issues with the staff to avoid making them feel scolded. The facility's policies on thawing foods, dry storage, and infection control were not followed, as evidenced by the observations and interviews conducted during the survey.
Inadequate Hand Hygiene Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN A during the care of two residents. RN A did not perform hand hygiene between glove changes while administering medication and changing the PEG tube dressing for a resident with cerebral palsy and gastrostomy status. This oversight occurred despite the nurse leaving the resident's room to obtain supplies, which should have prompted hand hygiene upon re-entry and before resuming care. In another instance, RN A did not adhere to proper hand hygiene protocols during wound care for a resident with a skin tear. The nurse placed wound care supplies on a porous towel on the floor, which was not a clean technique, and failed to perform hand hygiene between glove changes while cleaning and dressing the wound. This practice was contrary to the facility's infection control policy, which requires hand hygiene before and after glove use and the use of non-porous barriers for wound care supplies. Interviews with the DON, Regional RN Consultant, and the Administrator revealed that the facility's expectations for hand hygiene and infection control were not met. The DON and Regional RN Consultant emphasized the importance of hand hygiene and the use of non-porous barriers, while the Administrator acknowledged the infection control issue upon learning of the observations. The facility's policies clearly outlined the need for hand hygiene to prevent the transmission of infections, which was not followed in these instances.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, it was noted that a nurse's treatment cart on Hall 4 was left unlocked and unsupervised for approximately 10 minutes. The cart contained several ointments, nail clippers, dressings, and normal saline bottles. This incident occurred when RN A left the cart unattended while attending to a resident in their room. Interviews with RN A, the Director of Nursing (DON), and the Administrator revealed that it was expected for nursing staff to lock their medication carts when not in use. RN A admitted to being unaware that she had left the cart unlocked, stating it was an oversight. The DON and Administrator acknowledged the expectation for carts to be locked to prevent unauthorized access, with the Administrator suggesting that the oversight might have been due to staff nervousness during the surveyor's observation. The facility's policy, dated 2003, clearly indicated that medication carts must be locked when not in use or under direct supervision.
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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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