Big Spring Center For Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Big Spring, Texas.
- Location
- 3701 Wasson Rd, Big Spring, Texas 79720
- CMS Provider Number
- 676380
- Inspections on file
- 39
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Big Spring Center For Skilled Care during CMS and state inspections, most recent first.
Personal refrigerator food storage and temperature monitoring were not maintained for several resident rooms. Multiple refrigerators contained assorted food items, including dairy, condiments, sausages, and beverages, while no temp logs were found and internal temps were documented above the required range in some rooms. The ADM, DON, and DM stated residents or families were generally responsible for cleaning and maintaining the refrigerators, but there was no assigned daily staff task or log for monitoring temps or expired food.
A resident with Parkinson’s disease, moderate cognitive impairment, psychotic disorder, depression, and anxiety had an outdated PASARR PL1 that still indicated no mental illness. The MDS Coordinator stated she was responsible for keeping PL1s accurate and updated but was unaware of the psychotic disorder diagnosis, and no additional PL1 screening was available in the record.
Improper incontinent care was observed for a resident with Alzheimer's disease, muscle weakness, and frequent bladder incontinence who needed assistance with toileting hygiene. A CNA cleaned only part of the perineal area, did not clean the buttocks or front peri-area as observed, and then applied a new brief. The CNA acknowledged the omission, and the DON and ADM stated staff were expected to provide proper incontinent care per facility policy.
Failure to change gloves during incontinent care. A CNA provided perineal care to a resident with Alzheimer's disease and muscle weakness, cleaning from the vaginal area to the anus while bowel was present on the wipes, but did not change gloves when moving from dirty to clean tasks. The resident was frequently incontinent and required assistance with toileting hygiene. The CNA later acknowledged the error, and the DON and ADM stated gloves should be changed when contaminated and during incontinent care.
Two residents with dementia and wandering behaviors were involved in a physical altercation, during which staff failed to immediately report the incident and assess those involved, as required by facility policy. Multiple staff members, including a CNA, an LPN, and supervisory staff, did not follow abuse prevention and reporting procedures, resulting in delayed notification and assessment after the event.
The facility failed to inform residents about their rights to file grievances, resulting in 12 residents being unaware of how to access grievance forms or file grievances anonymously. The grievance procedure was not discussed in Resident Council meetings, and postings lacked necessary instructions. The Administrator acknowledged the oversight and the potential for unresolved resident issues.
The facility failed to properly store, label, and date food items in the kitchen's walk-in refrigerator, as observed during a survey. Several food items were found unsealed, unlabeled, or with expired dates. Staff interviews confirmed that all food should be sealed, dated, and used or discarded by the expiration date, as per facility policy. The Dietary Manager and dietary staff are responsible for monitoring compliance.
The facility failed to maintain an effective infection control program, as several CNAs did not adhere to proper hand hygiene protocols while providing care to residents. A CNA did not wash hands before assisting with incontinent care for a resident with multiple serious health conditions. Similarly, two CNAs did not follow proper handwashing procedures while providing peri care for another resident, who was cognitively intact and had a history of type 2 diabetes. Interviews revealed a lack of understanding and adherence to the facility's hand hygiene policy.
A facility failed to accurately complete the PASRR Level I assessment for a resident with PTSD, marking them as not having a mental illness. The MDS nurse was unaware of the PTSD diagnosis at admission, and no PASRR evaluation was conducted. Interviews revealed that the MDS nurse is responsible for ensuring PASRR accuracy, and the administrator stressed the importance of accurate assessments to prevent treatment delays.
A resident with cognitive impairment requested a room change due to feeling uncomfortable with a CNA who refused to change her adult brief. The Social Worker and DON did not file a grievance or investigate the issue, as the resident did not appear visibly upset. The facility's grievance policy was not followed, and the Administrator was unaware of the situation.
A resident in an LTC facility reported feeling uncomfortable and unsafe due to staff treatment, leading to a room change request. The facility failed to follow its abuse prevention policies, as staff did not report or investigate the resident's allegations. Interviews revealed that the resident felt neglected and dirty, and the facility's system for monitoring compliance with abuse policies was inadequate.
A resident received another resident's medications due to pre-cupping and labeling confusion, resulting in a significant drop in blood pressure and hospitalization. The error was identified and reported by the CMA, but the family was not immediately informed. The facility's medication administration policy was not followed.
A resident was administered another resident's medication, leading to a significant drop in blood pressure and hospitalization. The error was identified by a CMA and reported to an LVN, but the physician and family were not notified immediately, contrary to facility policy.
A resident with multiple medical conditions and a high risk for falls was injured during a transfer using a sliding board by an untrained nurse aide. The incident was not reported immediately, and the resident later reported the fall, leading to his discharge from the facility. Staff interviews revealed lapses in training and communication.
Personal Refrigerator Food Storage and Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to maintain safe and sanitary storage of residents’ food items in personal refrigerators for 4 of 21 resident rooms reviewed. During observations, multiple resident room refrigerators contained a variety of food items, including condiments, dairy products, sausages, cheese, yogurt, and beverages, while no temperature logs were located on or around the refrigerators. In one room, the refrigerator thermometer showed 42 F on two separate observations; in another room, it showed 46 F on two separate observations. In one refrigerator, food items included five bottles of grape and strawberry jelly, peanut butter, swirled peanut butter and jelly, soda, mayonnaise, sour cream, pickles, and water, with the internal temperature recorded at 42 F. In another refrigerator, four cans of soda and two containers of unknown food contents were present, and the thermometer showed 46 F. In a third refrigerator, two packs of hot link sausages were present, including one opened package and one unopened package, along with a bottle of mustard that had an open date written as 04/03/22 and a bottle of water. In a fourth refrigerator, items included snack packs with unknown white contents, yogurt, cream cheese spread, butter, chocolate bars, American cheese singles, mayonnaise, grape jelly, shredded cheese, and eleven cans of soda, including two damaged and misshaped cans. The ADM stated residents were responsible for maintaining their own personal refrigerators, including cleaning them, storing food properly, and discarding spoiled items, and said staff were not assigned to check personal refrigerators or document temperatures on a log. The DON stated staff could assist residents if needed and that expired or spoiled food could be discarded after notifying the resident and getting permission, but also stated there was no daily checklist or task assigned for staff to check refrigerators. The DM stated she placed thermometers in personal refrigerators and checked temperatures during morning rounds, but she did not keep temperature logs. The facility policy stated residents and/or responsible parties were responsible for care and maintenance of personal refrigerators, that housekeeping could assist at least weekly, and that food that is expired, spoiled, or moldy could be discarded.
PASARR Level 1 Not Updated for Resident With Psychotic Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASARR) program for one resident reviewed for PASARR screening. Resident #13 had an undated face sheet showing a history of Parkinson’s disease, psychotic disorder with hallucinations due to a known physiological condition, and anxiety. The quarterly MDS dated [DATE] showed a BIM’s score of 12, indicating moderate cognitive impairment, and listed psychotic disorder, depression, and anxiety as active diagnoses. The care plan initiated on 1/07/2025 included a focus that the resident required an antipsychotic medication, with goals and interventions related to medication administration, pharmacy consultation, and education about risks and side effects. Resident #13’s PASARR Level 1 form dated 4/19/2022 indicated “No” for mental illness under Section C0100, and no additional PL1 screenings were provided by the facility. During interview, the MDS Coordinator stated she was responsible for ensuring PL1s were accurate and updated, but she was not aware of the resident’s psychotic disorder diagnosis and acknowledged that the resident did not have another PL1 available. The Administrator stated the MDS Coordinator was responsible for ensuring PL1s were accurate and updated and said new mental illness diagnoses were discussed in weekly IDT meetings, but Resident #13’s diagnosis may have been missed.
Improper Incontinent Care During Perineal Hygiene
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a resident who was frequently incontinent of bladder and required supervision or touching assistance for toileting hygiene. The resident had diagnoses of Alzheimer's disease and muscle weakness, and the care plan directed incontinence care at least every 2 hours. During an observation, a CNA provided incontinent care while the resident was lying on her left side, cleaned from the vaginal area to the anus, and then placed a new brief without any observation of cleaning the buttocks area or the peri-area on the front side. The resident was then turned onto her back and the brief was fastened. During interview, the CNA stated there was no reason she did not clean the resident's buttocks area or front side and acknowledged she had been trained in incontinent care. The CNA stated she should have cleaned the front side of the resident and identified urinary tract infection as a potential negative outcome. The DON and ADM stated CNAs were responsible for proper incontinent care and that staff had been trained and competency checked, and the facility policy required cleaning the pubis and perineal area from clean to dirty and then cleaning the buttocks and anal area after repositioning the resident.
Failure to Change Gloves During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents reviewed for infection control. During observation of incontinent care for a resident admitted with Alzheimer's Disease and muscle weakness, the CNA cleaned the resident from the vaginal area to the anus while the resident was lying on her side, and bowel was observed on the disposable wipes during cleaning. No glove change was observed when the CNA moved from dirty to clean tasks, and the CNA later removed gloves and gown and washed hands after the care was completed. The resident's quarterly MDS indicated the resident required supervision or touching assistance for toileting hygiene and was frequently incontinent. The care plan identified occasional bladder incontinence with interventions to provide incontinence care at least every 2 hours. During interview, the CNA stated there was no reason she did not change her gloves, said she got nervous and did not have any extras, and acknowledged she should have changed her gloves when going from dirty to clean. The DON and ADM both stated gloves should be changed when contaminated and during incontinent care, and the CNA proficiency audit for perineal care documented satisfactory skills for proper handwashing and preventing cross contamination.
Failure to Implement and Follow Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement and follow its written policies and procedures designed to prohibit and prevent abuse and neglect, specifically in relation to a resident-to-resident altercation involving two residents with dementia and wandering behaviors. On the day of the incident, a CNA witnessed one resident hitting another with a shoe and restraining him on a bed, while the second resident was yelling for help. The CNA separated the residents and attempted to report the incident to the nursing staff, but no one was available at the nurse's station. The CNA did not report the incident to the charge nurse or other appropriate personnel until the following day, resulting in a delay in both assessment and reporting. Other staff members, including another CNA and an LVN who were informed of the altercation during shift change, also failed to report the incident to facility management, assuming it had already been reported. The ADON was not made aware of the incident until the next morning, at which point both residents were assessed. One resident was found to have a new abrasion on his nose, while the other had no visible injuries. The delay in reporting and assessment was contrary to the facility's abuse policy, which requires immediate reporting and assessment of all residents involved in such incidents. Interviews with staff and record reviews confirmed that the facility's abuse prevention policies were not followed by multiple staff members, including the CNA, LVN, ADON, and the former administrator. The facility's policy mandates that all allegations of abuse be reported immediately to the administrator and appropriate authorities, and that residents involved in altercations be promptly assessed for injuries. The failure to adhere to these procedures resulted in a delayed response to the incident and a lack of timely assessment and reporting, as required by both facility policy and regulatory standards.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to provide information to residents and their representatives on their rights related to filing grievances or concerns. During a Resident Council meeting, 12 confidential residents reported that they did not have access to the Grievance form, were unaware of the option to file grievances anonymously, and had not been informed about the grievance procedure. Additionally, they had not seen any postings of the grievance procedure in prominent locations within the facility. These residents were also unaware of where to obtain a grievance form, whom to submit it to, and the process that follows once a grievance is filed. The facility's grievance policy, last updated in 2016, states that a copy of the grievance/complaint procedure should be posted on the resident bulletin board. However, observations revealed that while information about the administrator being the grievance officer was displayed, instructions regarding the grievance procedure were not included in any prominent postings. Grievance forms were not readily available, and there was no established procedure for submitting grievances anonymously. An interview with the Administrator (ADM) revealed that she was responsible for overseeing the grievance process and that grievance forms were kept in a folder outside her office. However, the ADM acknowledged that the forms' availability was not helpful if residents did not know where to find them. The ADM also stated that staff typically completed grievance forms for residents, and there was no procedure for anonymous submissions, despite the presence of a box outside her office that could be used for this purpose. The ADM was unaware that the grievance procedure was not being discussed in Resident Council meetings, and she recognized that the lack of adherence to the grievance policy could result in unresolved resident issues.
Failure to Properly Store and Date Food in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not properly store, label, and date food items in the walk-in refrigerator. Observations revealed several food items, including a plastic container with mixed fruit, a metal bowl covered with tin foil, and containers labeled with expired dates or no dates at all. These items were not sealed or dated as required by the facility's policy. Interviews with staff members, including the Dietary Manager (DM) and another staff member, confirmed that all food in the refrigerator should be sealed and dated, and used or discarded by the expiration date. The staff acknowledged that they had received training on these procedures. The Administrator (ADM) also stated that the DM and dietary staff are responsible for monitoring the refrigerator and ensuring compliance with food storage policies. The facility's policy, dated 2012, mandates that open packages of food be stored in closed containers with covers or sealed bags and dated when opened.
Inadequate Hand Hygiene Practices in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of several CNAs who did not adhere to proper hand hygiene protocols while providing care to residents. Specifically, CNA E did not wash hands before assisting with incontinent care for Resident #40, who had a history of multiple serious health conditions, including pneumonia, sepsis, and end-stage renal disease. During the care process, CNA E also failed to wash hands after removing gloves and only rinsed hands without using soap, which is against the facility's hand hygiene policy. Similarly, CNAs H and I did not follow proper handwashing procedures while providing peri care for Resident #51, who was cognitively intact and had a history of type 2 diabetes and other health issues. Both CNAs washed their hands for significantly less time than required by the facility's policy and the CDC guidelines. Additionally, CNA I began interacting with the resident before donning the necessary PPE, and both CNAs struggled to clean dried feces from the resident, indicating inadequate care. Interviews with the CNAs revealed a lack of understanding and adherence to the facility's hand hygiene policy, despite having received training. The facility's administrator confirmed the expectation for proper handwashing and the potential risks of not following these protocols, such as the spread of infections and skin breakdown. The facility's policies on hand hygiene, enhanced barrier precautions, and perineal care were not followed, leading to the observed deficiencies.
Inaccurate PASRR Screening for Resident with PTSD
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessment for a resident, which did not reflect the resident's diagnosis of Post-Traumatic Stress Disorder (PTSD). This oversight was identified during a review of the resident's records, which showed that the PASRR Level I screenings conducted on two separate occasions incorrectly marked the resident as not having a mental illness, despite the presence of a PTSD diagnosis upon admission. The MDS nurse, responsible for checking the PASRR for accuracy, was unaware of the PTSD diagnosis at the time of admission, and no PASRR evaluation was conducted. Interviews with the MDS nurse and the facility administrator revealed that the MDS nurse was not in her current role at the time of the resident's admission but is responsible for ensuring the accuracy of PASRR screenings and entering admitting diagnoses into the electronic medical record. The administrator confirmed that the MDS Coordinator is responsible for completing PASRR evaluations and emphasized the importance of accurate PASRR assessments to prevent delays in treatment and referrals. The facility's policy requires a review of the PASRR Level 1 screening form for completion and correctness prior to admission, but this was not adhered to in this case.
Failure to Address Resident Grievance Regarding Staff Treatment
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident who requested a room change due to feeling uncomfortable with a staff member. The resident, who had a cognitive communication deficit and was moderately impaired, expressed that a CNA was mean to her and refused to change her adult brief, making her feel unsafe. Despite the resident's request to move rooms, no grievance was filed, and the reason for the move was not documented or investigated. The Social Worker acknowledged the resident's request to move but did not file a grievance or investigate further, as the resident did not appear visibly upset. The Social Worker was aware of the facility's grievance policy but did not follow it, which could potentially harm residents or compromise their rights. The Director of Nursing (DON) also did not follow up on the reason for the room change, assuming it was the resident's choice without further inquiry. The Administrator, who was new to the facility, was not informed of the resident's discomfort or the grievance process not being followed. The facility's grievance policy requires that grievances be reported and investigated, with the Administrator or their designee overseeing the process. However, the policy was not adhered to, and the resident's concerns were not addressed according to the established procedures.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for one of the residents reviewed for abuse. The Social Worker did not follow the facility's abuse policy by failing to report the resident's request for a room change and her discomfort with the staff to the abuse preventionist. Additionally, a confidential interview revealed that the facility's abuse policy was not followed when the resident reported feeling uncomfortable due to staff treatment from several CNAs and an LVN. The report highlights that LVN C did not report an allegation of abuse to the abuse preventionist when informed by an unidentified staff member that the resident felt uncomfortable and dirty due to the staff. The facility's policies, including those on resident rights and abuse/neglect, emphasize the importance of reporting and investigating any allegations of abuse or neglect. However, the facility's staff, including the Social Worker and LVN C, failed to adhere to these policies, which could place residents at risk for abuse and neglect. Interviews with the resident and staff revealed that the resident felt unsafe and uncomfortable due to the actions of certain staff members. Despite the resident's request for a room change and her expressed discomfort, the facility did not document or investigate the allegations. The DON and ADM were unaware of the resident's concerns, and the facility's system for monitoring and ensuring compliance with abuse policies was inadequate, as evidenced by the lack of reporting and investigation of the resident's allegations.
Significant Medication Error Due to Pre-Cupping and Labeling Confusion
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving Resident #1. Certified Medication Aide (CMA) A administered medications intended for Resident #2 to Resident #1, resulting in a significant drop in Resident #1's blood pressure and necessitating her transfer to the hospital. The error was identified when CMA A realized the mistake shortly after administering the medications and reported it to Licensed Vocational Nurse (LVN) A. LVN A assessed Resident #1 and found her blood pressure to be critically low, leading to the initiation of intravenous fluids and eventual transfer to the emergency room as per the physician's orders. The family member of Resident #1 was not immediately informed about the medication error, which caused further distress when they learned about it from the hospital staff later on. The facility's Director of Nursing (DON) was also not promptly informed about the urgency of the situation by LVN A. The error was attributed to the practice of pre-cupping medications and labeling them with residents' names, which led to confusion due to the similarity in the names of Resident #1 and Resident #2. CMA A, who was filling in for another CMA, was not familiar with the medication carts and the process, which contributed to the error. The facility's policy on medication administration was not followed, as medications were removed from their unit dose packaging in advance, increasing the risk of drug administration errors.
Failure to Notify Physician and Family of Medication Error
Penalty
Summary
The facility failed to immediately notify the resident's physician and representative when there was a significant change in the resident's physical status. Specifically, Resident #1 was administered Resident #2's medication, which led to a significant drop in blood pressure, necessitating an IV administration and subsequent transfer to the hospital. The error was discovered by a Certified Medication Aide (CMA) who reported it to a Licensed Vocational Nurse (LVN), but the physician and responsible party were not notified immediately as required by the facility's policy. Resident #1, who had multiple diagnoses including Alzheimer's disease, epilepsy, and hypertension, was mistakenly given medications intended for Resident #2. This error occurred because the medications were pre-cupped and labeled incorrectly, leading to confusion. The CMA identified the error shortly after administration and reported it to the LVN, who then monitored the resident's blood pressure, which remained critically low. Despite the severity of the situation, the physician and the resident's family were not informed immediately. Interviews with staff revealed that the medication error was due to improper labeling and pre-cupping of medications. The DON was not aware of the pre-cupping practice and was informed of the error only after the resident's condition had worsened. The facility's policies clearly state that any medication errors should be reported immediately to the physician and the resident's family, which did not happen in this case. This failure to follow protocol placed the resident at significant risk and delayed appropriate medical intervention.
Failure to Provide Adequate Supervision and Training for Resident Transfers
Penalty
Summary
The facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, specifically for one resident who was transferred using a sliding board by a nurse aide who had not been trained to use it. The resident, who had a pressure ulcer on his right heel and an acquired absence of his left leg below the knee, was cognitively intact and used a wheelchair. During a transfer to the toilet, the sliding board moved, causing the resident to fall and injure his hip area. The incident was not reported immediately, and the nurse aide admitted to not having received training on the use of the sliding board. The resident's medical records indicated he was at medium risk for falls due to various conditions, including hypotension, vertigo, Parkinson's disease, and osteoporosis. Despite these risks, the nurse aide proceeded with the transfer without seeking assistance or reporting the incident to the charge nurse. The resident later reported the fall to the Director of Rehabilitation and a Physical Therapist Assistant, who confirmed the injury and the improper use of the sliding board. Interviews with staff revealed that the nurse aide did not receive a shift report and was unaware of the resident's specific needs, including his missing leg. The Director of Nursing confirmed that the nurse aide had not been trained to use the sliding board and that the incident was considered a fall. The facility's policies and procedures for fall prevention and incident reporting were not followed, leading to the resident's injury and subsequent discharge from the facility.
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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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