Brentwood Terrace Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Paris, Texas.
- Location
- 2885 Stillhouse Road, Paris, Texas 75460
- CMS Provider Number
- 676045
- Inspections on file
- 41
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brentwood Terrace Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple comorbidities, intact cognition, and total dependence for peri-care and bed mobility was care planned and ordered for incontinence management and skin protection, with an expectation from nursing leadership that staff round at least every two hours. On one occasion, the resident reported being left in a soiled brief for over five hours, leading to urine-saturated bed linens; an Ombudsman later found the resident crying and soaking wet and observed aides entering to provide care after the concern was raised to the ADON. Staff interviews indicated reliance on the resident’s call light use, lack of recall of the resident being soaked, and incomplete documentation of the frequency of incontinent care, demonstrating a failure to provide timely toileting and incontinent care as recommended.
A CNA failed to treat a resident with respect and dignity during assistance with a TV, including making dismissive comments and leaving the room without explanation despite the resident's confusion. The resident, who had visual and hearing impairments and was dependent on staff for various needs, reported staff rudeness and negative remarks. Interviews confirmed the CNA did not recognize the dignity issues in her actions, contrary to facility policy and expectations stated by the DON and Administrator.
A resident with quadriplegia and migraines did not receive prescribed Qulipta for three days because nursing staff failed to ensure timely pharmacy delivery and did not notify the physician or appropriate supervisory staff about the missed doses. Interviews revealed that staff were aware of the medication shortage but did not take required actions to resolve the issue or communicate the problem, contrary to facility policy.
Two residents did not receive prescribed medications as ordered, including missed insulin and blood sugar checks for a diabetic resident attending an outside program, and a missed dose of Metoprolol for another resident with a gastrostomy tube. Nursing staff failed to notify the physician or ensure medication administration in accordance with facility policy, resulting in significant medication errors.
Surveyors found that a nurse left a medication cart unlocked while unattended, and two residents had medications (an inhaler and nystatin cream) unsecured in their rooms without proper assessment for self-administration or physician orders. Facility staff were unaware of the presence of these medications at bedside, and policies requiring secure storage and assessment for self-administration were not followed.
Staff failed to follow infection control protocols by not performing proper hand hygiene and not donning required PPE, such as gowns, during incontinent care, IV medication administration, and gastrostomy tube medication administration for residents on enhanced barrier precautions. These lapses occurred despite staff training and clear signage, affecting multiple residents with complex medical needs.
A resident with severe cognitive impairment and dementia was not provided with care plan meetings that included her representative, as required. The facility did not document or conduct quarterly care plan conferences, and the resident's representative confirmed she was never invited to participate. Staff interviews revealed that the responsibility for organizing these meetings was not fulfilled, resulting in the representative's exclusion from the care planning process.
A resident with a history of behavioral issues and cognitive impairment was struck in the head by another resident with psychiatric diagnoses and poor impulse control after a dispute involving a wheelchair. The incident was witnessed by a CNA, and records showed both residents had care plans addressing their behavioral risks, but staff intervention occurred only after the physical contact had taken place.
A resident with multiple mental health diagnoses was incorrectly coded on the MDS assessment as not having a serious mental illness or intellectual disability in the PASRR section, despite care plan documentation showing PASRR positivity and related services. Staff interviews confirmed the assessment should have reflected the resident's true status, and there was no specific policy for ensuring MDS accuracy.
A resident with a feeding tube and multiple medical conditions did not receive a scheduled enteral feeding as ordered by the physician. Staff interviews confirmed that the nurse responsible did not administer the feeding, despite care plan interventions and facility policy requiring adherence to physician orders for tube feedings.
A resident with COPD was observed receiving continuous oxygen therapy without a physician's order documented in the medical record. Nursing staff and administration were unaware of the missing order until notified by surveyors, despite facility policy requiring a physician's order specifying oxygen administration details.
The facility's kitchen was found to have significant sanitation issues, including a dirty microwave, a deep fryer with old grease, and sheet pans with grease buildup. Staff interviews revealed that cleaning protocols were not consistently followed, with the microwave not cleaned after use and the deep fryer not cleaned after frying fish. The Dietary Manager and Administrator acknowledged the importance of cleanliness to prevent foodborne illness, but practices did not meet professional standards.
A CNA in an LTC facility failed to communicate with four residents during care, leading to feelings of disrespect and rudeness. Despite the residents having intact cognition and care plans emphasizing communication, the CNA did not engage with them verbally. This issue was reported by the residents, but previous complaints had not led to significant action beyond initial training.
The facility failed to address and document grievances from the resident council regarding call light response times. Despite repeated concerns raised in meetings, there was no documentation of efforts to resolve these issues. Staff interviews revealed a lack of communication and follow-up, with the Administrator admitting awareness of the ongoing problem but failing to provide documentation of grievances or resolutions.
A resident's OOH-DNR form was found incomplete, missing the physician's printed name, during a review at an LTC facility. The resident, with severe cognitive impairment due to dementia, had an active DNR order. The social worker responsible for DNRs admitted to missing this detail during random audits. The facility's administrator emphasized the importance of complete DNR documentation to respect resident preferences.
A facility failed to update a resident's care plan to reflect her current needs, as she no longer required a fall mat due to her inability to transfer or ambulate independently. Despite discussions in morning meetings, the care plan was not revised, leading to a deficiency in providing person-centered care.
The facility failed to ensure proper storage of medications for two residents, leading to medications being left at the bedside. A resident with COPD had nebulizer medication left unattended, while another resident with Parkinson's had various medications at his bedside without proper assessment for self-administration. Staff acknowledged the importance of secure medication storage to prevent misuse and ensure safety.
A resident with dementia and malnutrition did not receive her prescribed iced tea during a lunch meal, contrary to her dietary plan. The RN, DON, and Administrator acknowledged the importance of serving drinks with meals to prevent dehydration, but no monitoring system was in place prior to the surveyor's intervention.
The facility failed to provide sufficient support personnel in the kitchen, resulting in food being served at improper temperatures and meals being delayed. The cook, working double shifts due to understaffing, did not reheat food held below the required 135 degrees Fahrenheit. The Dietary Manager confirmed long-standing issues with the steam table and the stress caused by the lack of staffing.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Issues included improper thawing of meat, use of unpasteurized eggs, and failure to maintain proper food temperatures. Additionally, the three-compartment sink was not used correctly for sanitizing equipment.
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for three residents. One resident's care plan was not updated after discontinuing an antidepressant, another's was not revised after multiple falls, and a third's was not updated following consecutive falls. This led to inaccurate care information and potential risks for the residents.
The facility failed to ensure necessary grooming and personal hygiene services for seven residents, including missed baths and showers, and one resident not being shaved due to a missing razor. These deficiencies were identified through observations, interviews, and record reviews, revealing inconsistent hygiene care and resulting in feelings of uncleanliness among the residents.
The facility failed to ensure that four staff members, including two LVNs, a Social Worker, and a Housekeeping Supervisor, completed their required annual restraint training. This oversight was due to a lack of clarity and accountability in the training program, placing residents at risk for inappropriate use of restraints.
The facility failed to notify a resident's family of new skin concerns, including shearing, hematoma, bruising, and redness, despite the care plan's directives and facility policy. The lapse in communication and documentation was confirmed through record reviews and interviews with staff and family members.
The facility failed to inform a resident of changes to their Medicare/Medicaid coverage and potential out-of-pocket costs by not providing a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) upon discharge from skilled services. The MDS Coordinator admitted to forgetting the task, and the Administrator confirmed the responsibility lies with the MDS Coordinator and BOM.
A resident with multiple health issues continued to miss scheduled baths despite a grievance filed by her family member. The facility's records and interviews with staff revealed a lack of oversight and accountability in ensuring the resident received her scheduled baths, leading to ongoing dissatisfaction and potential risks for the resident.
The facility failed to ensure accurate MDS assessments for a resident, incorrectly indicating the use of an antidepressant medication that had been discontinued. The error was confirmed by the MDS Coordinator, and the DON and Interim Administrator emphasized the importance of accurate assessments.
The facility failed to implement a comprehensive care plan for a resident at risk for falls, as the required fall mat was not present at the bedside during multiple observations. Staff interviews confirmed the oversight and acknowledged the importance of the fall mat in preventing injury.
The facility failed to provide consistent and scheduled in-room activities for a resident with quadriplegia, major depressive disorder, and anxiety disorder. The resident's preferences for various activities were not care planned or documented, leading to feelings of sadness and loneliness. The Activity Director was unable to provide these activities consistently due to being overburdened and lacking assistance.
The facility failed to ensure proper treatment and services to prevent urinary tract infections for two residents. One resident's urinary catheter was not secured properly, and another resident did not receive adequate incontinent care, including improper glove changes and hand hygiene.
The facility failed to obtain weekly weights as ordered for a resident with multiple diagnoses, including dementia and malnutrition. Interviews revealed that the responsibility for obtaining weights was assigned to aides and LVNs, but the weights were overlooked on two occasions. The facility's policy required weights to be documented at admission, readmission, and monthly unless otherwise ordered.
The facility failed to provide proper respiratory care for two residents. One resident's nebulizer mask was not stored in a bag when not in use, and another resident received oxygen at an incorrect rate. These deficiencies were confirmed through observations and staff interviews, indicating non-compliance with professional standards and physician orders.
The facility failed to monitor side effects and behaviors for a resident on multiple psychotropic medications and administered PRN Clonazepam to another resident without adequate indication or prior interventions. This lack of monitoring and documentation could lead to unnecessary medication use and adverse side effects.
The facility failed to ensure all drugs were stored in a locked compartment, as a nurse treatment cart was found unlocked and unattended. The nurse on duty admitted the cart should be locked, and keys were found lying on top of the cart. Interviews with the ADON, ADM, and DON confirmed the expectation that carts be locked to prevent unauthorized access.
The facility failed to ensure appropriate antibiotic use and documentation for a resident with a UTI, leading to potential risks of unnecessary antibiotic use and increased antibiotic-resistant infections. Key protocols, including SBAR assessments and logging antibiotic use, were not followed.
Failure to Provide Timely Incontinent Care Resulting in Saturated Bed Linens
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of activities of daily living related to hygiene, grooming, and incontinent care for one cognitively intact resident. The resident, an older female with multiple medical diagnoses including cerebral infarction, COPD, dysphagia, DM2, bipolar disorder, heart failure, hyperlipidemia, CKD stage 3, and seizures, was dependent for peri-care/toilet hygiene, bed mobility, transfers, and lower body dressing, and was incontinent of bowel and bladder. Her care plan and physician orders reflected incontinence, diuretic use, and risk for skin breakdown, with topical Nystatin ordered for yeast infection in the groin and abdominal folds. The DON stated an expectation that nursing staff round at least every two hours to ensure incontinent care needs are met. On one date, the resident reported she had been left in a soiled brief for over five hours, resulting in bed linens saturated with urine. The Ombudsman corroborated that on that date, at approximately late morning, she found the resident crying and “soaking wet,” and allowed the resident to call the state hotline. The Ombudsman reported notifying the ADON and observing aides enter the room to provide peri-care while she spoke with the ADON. On a later observation date, the resident told the surveyor she was soiled with urine and waiting to be changed; the surveyor noted a slight urine odor and a brief that was not saturated and appropriately sized, and also noted the resident’s call light was not on during that interview. Staff interviews showed that CNAs, hospitality aides, an LVN, the ADON, and the DON all acknowledged the resident used XXL briefs kept in her room and typically used the call light when she needed to be changed. Multiple staff members, including CNAs and hospitality aides, stated they did not recall the resident being found soaked or excessively wet, and one CNA working the relevant hall on the date in question stated she was rushed but felt she completed her tasks, though she could not recall how often she checked on the resident. The DON and Administrator both stated expectations that incontinent care be provided as needed and that staff round at least every two hours, but the nurse aide task documentation for the date in question only showed incontinent care checked off by shift without indicating the number of times peri-care was provided. No facility incontinent care or ADL policy was reviewed prior to survey exit. The facility failed to ensure incontinent care was provided every two hours as recommended, resulting in the resident’s bed linens being saturated with urine.
Failure to Treat Resident with Dignity and Respect During Care Interaction
Penalty
Summary
A certified nursing assistant (CNA) failed to treat a resident with respect and dignity during an interaction involving assistance with the resident's television. The resident, who had chronic obstructive pulmonary disease, heart failure, anxiety disorder, visual impairment, and hearing difficulties, was dependent on staff for emotional, intellectual, physical, and social needs. The resident reported that staff were rude, spoke negatively about him, and that he had difficulty operating his TV remote due to his visual impairment. During an observation, the CNA entered the resident's room, made a dismissive comment about the resident's request for the TV, and failed to address the resident directly before leaving the room to get batteries, despite the resident expressing confusion as she exited. Interviews with the CNA revealed a lack of awareness regarding the importance of explaining actions to residents and addressing them respectfully, especially when leaving the room. The CNA did not perceive her actions as disrespectful or as a violation of the resident's dignity. The Director of Nursing (DON) and the Administrator both stated that staff are expected to explain their actions to residents and ensure their needs are met before leaving the room. The facility's policy requires that residents be treated with respect and dignity, and that their individual needs and preferences be accommodated.
Failure to Administer Prescribed Medication Due to Pharmacy and Communication Lapses
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for a resident with quadriplegia and migraines. The resident did not receive his prescribed Qulipta medication on three consecutive days, as documented in the Medication Administration Records (MARs) for those dates. Interviews revealed that nursing staff were aware the medication was unavailable due to a delay in pharmacy delivery, but did not contact the pharmacy to expedite delivery or notify the physician about the missed doses. The resident reported to surveyors that he was informed by nurses that his medication was out of stock. Further interviews with nursing staff indicated a lack of clarity regarding responsibility for contacting the pharmacy and notifying the physician when medications were not available. The Director of Nursing (DON) and Administrator both stated that nurses were expected to ensure medications were administered as ordered and to notify appropriate personnel if medications were missed, but neither was made aware of the missed doses. The facility's policy required medications to be administered as prescribed and in accordance with physician orders, which was not followed in this instance.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors due to lapses in medication administration. One resident, a male with diagnoses including type 2 diabetes mellitus, schizophrenia, and hypertension, did not receive his ordered blood sugar checks or insulin for 21 out of 31 days in May. The resident attended an adult habilitation center Monday through Friday, where staff were not authorized to administer medications. Facility nurses documented the missed doses as the resident being away but did not notify the physician or ensure alternative arrangements for medication administration. The medical director and nursing staff were unaware that the resident was not receiving his prescribed blood sugar checks and insulin during his time at the center. Another resident, a male with a history of dysphagia, gastrostomy hemorrhage, muscle wasting, and hypertension, did not receive his scheduled dose of Metoprolol via gastrostomy tube at 4:00 p.m. on a specific date. The resident reported not receiving the medication, and the responsible nurse confirmed it was her duty to administer medications on time. The facility's policies require medications to be administered as ordered and for the physician to be notified if a dose is missed, but this protocol was not followed in this instance. Interviews with facility staff, including nurses, the medical director, the regional nurse consultant, and the administrator, confirmed that the expected practice was to administer medications as ordered and to notify the physician if a dose was missed. However, in both cases, the required medications were not administered as prescribed, and appropriate notifications were not made, resulting in significant medication errors for both residents.
Failure to Secure Medications and Assess Self-Administration
Penalty
Summary
Surveyors identified that a registered nurse failed to secure a medication cart when leaving it unattended to check a resident's blood sugar. The nurse admitted to forgetting to lock the cart and acknowledged responsibility for ensuring it was secured. Facility leadership, including the Regional Compliance Nurse and Administrator, confirmed that medication carts are expected to be locked when unattended to prevent unauthorized access. Additionally, a resident with COPD and asthma was observed multiple times with a labeled Albuterol inhaler on her dresser, which she reported using as needed and stated she brought from home. The medication was also found on the nurse's medication cart at one point, and the resident indicated she had informed someone at the facility about possessing the inhaler, though staff were unaware. The resident had not been assessed for self-administration of medication, and the inhaler was not secured as required by facility policy. Another resident was found with a tube of nystatin cream on her bedside table, which she stated was brought by her husband and used for itching. There was no physician order for the cream, and the resident had not been assessed for self-administration. Staff later instructed the resident to have the medication removed, but were initially unaware of its presence. Facility policy requires medications to be stored securely and only accessible to authorized personnel, and mandates assessment and physician order for self-administration, which was not completed in these cases.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not following proper infection control protocols during resident care. In one case, a CNA provided incontinent care to a female resident with dementia and congestive heart failure without changing gloves or performing hand hygiene between cleaning the resident's front and back areas. The CNA then touched clean items and assisted the resident to her wheelchair while still wearing the same contaminated gloves, only removing them and washing hands after completing all care tasks. Interviews confirmed that the CNA was aware of the correct procedures but did not follow them during the observed care. In another instance, an LVN administered IV medication to a male resident with sepsis and cellulitis, who was on enhanced barrier precautions (EBP), without donning a gown as required by the resident's care plan and facility policy. The LVN performed hand hygiene and wore gloves but omitted the gown, later stating that nervousness caused her to forget this step. The resident's care plan and EBP signage in the room clearly indicated the need for both gloves and gown during high-contact care activities, including IV medication administration. Additional deficiencies were observed with another male resident with quadriplegia and a feeding tube, also on EBP. An LVN administered medications via the resident's gastrostomy tube without wearing a gown, despite the presence of PPE supplies and EBP signage in the room. Furthermore, two CNAs provided personal care, including bathing, to the same resident without donning gowns. Both staff members acknowledged their training on PPE use and the importance of infection control, but failed to comply with established protocols during the observed care activities.
Failure to Involve Resident Representative in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident's representative was invited to participate in the development and review of the resident's person-centered care plan. The resident, an elderly female with dementia, muscle weakness, and anxiety, had been admitted to the facility several months prior. Her medical records indicated severe cognitive impairment, and her care plan included interventions to communicate with the resident and her family regarding her needs. However, there was no documentation in the electronic medical record that a care plan conference had been completed or uploaded since her admission. Interviews with the resident's representative confirmed that she had not been invited to any care plan meetings since the resident's admission. Facility staff, including the social worker, registered nurse coordinator, administrator, and MDS coordinator, acknowledged that care plan meetings should occur at least quarterly and that the social worker was responsible for ensuring these meetings were conducted. Despite this, the required care plan meetings had not taken place, and the representative had not been given the opportunity to participate in the resident's care planning process.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when one resident physically struck another in the head. Specifically, a male resident with a history of dementia, Alzheimer's disease, and behavioral problems, including physical aggression, was hit in the head by a female resident diagnosed with bipolar disorder, schizophrenia, and poor impulse control. The incident occurred in the day room when the male resident reportedly ran over the female resident's foot with his wheelchair, prompting her to hit him in the head. This event was witnessed by a CNA, who heard the altercation and observed the physical contact. Record reviews indicated that the male resident had documented short- and long-term memory problems and a history of behavioral issues, while the female resident had a care plan addressing her potential for physical behaviors and poor impulse control. The care plan for the female resident included interventions for immediate staff intervention in the event of physical behaviors toward others. Despite these documented risks and interventions, the physical altercation occurred, and staff intervention only took place after the incident had already happened. Interviews with staff and residents confirmed the occurrence of the incident, with the CNA stating she intervened immediately after hearing the altercation and witnessing the physical contact. The facility's policy states that residents have the right to be free from abuse, including abuse by other residents. However, the incident demonstrated a failure to prevent resident-to-resident abuse as required by facility policy and regulatory standards.
Inaccurate MDS Assessment Coding for PASRR Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with significant mental health diagnoses. Specifically, the MDS for a female resident with a history of bipolar disorder, schizophrenia, delusional disorder, and anxiety disorder was incorrectly coded in the PASRR (Preadmission Screening and Resident Review) section. The assessment marked that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite documentation in the care plan indicating that the resident was PASRR positive and receiving habilitation coordination and independent living skills training. Interviews with facility staff, including the MDS Coordinator, Regional Reimbursement Specialist, Regional Compliance Nurse, and Administrator, confirmed that the MDS should have been marked to reflect the resident's PASRR status. The Administrator acknowledged that monitoring of MDS accuracy was done through random audits or spot checks but could not recall the last audit performed. There was no specific policy or procedure in place regarding MDS assessment accuracy, and the facility relied on the RAI manual for guidance.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident who required enteral feeding via a gastrostomy tube. The resident, a male with diagnoses including dysphagia, gastrostomy hemorrhage, and muscle wasting, had physician orders for Nutren 2.0 to be administered through his PEG tube with specified flushes. The comprehensive care plan identified risks such as aspiration, weight loss, and dehydration, and included interventions to administer tube feeding as ordered. However, on a specified date, the resident did not receive his scheduled feeding, as confirmed by his own report and subsequent staff interviews. Interviews with nursing staff and facility leadership confirmed that it was the nurse's responsibility to administer the enteral feeding as ordered and that failure to do so could result in weight loss and other complications. The facility's policy assigned responsibility for tube feeding administration to the nursing service department. The deficiency was identified through record review and interviews, which established that the resident's enteral feeding was not administered according to physician orders on the specified date.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of COPD who was receiving oxygen therapy had a corresponding physician's order in her medical record. The resident was observed on multiple occasions using oxygen via nasal cannula, with the oxygen concentrator set at 2 liters per minute. The resident reported wearing oxygen at all times due to her COPD. Review of the resident's care plan indicated she was to receive oxygen therapy, but it did not specify the number of liters to be administered. Additionally, the physician order summary did not contain an order for oxygen, and the admission MDS had not yet been completed. Interviews with nursing staff and facility administration revealed that the lack of an oxygen order was not identified until brought to their attention by the surveyor. The charge nurse responsible for the resident's care and the regional compliance nurse both confirmed that an order should have been present in the electronic medical record. The facility's policy on oxygen administration requires a physician's order specifying the amount and method of oxygen delivery, which was not followed in this case.
Kitchen Sanitation Deficiencies Observed
Penalty
Summary
The facility failed to maintain cleanliness and proper sanitation in its kitchen, which could potentially place residents at risk for foodborne illness. During an initial tour observation, surveyors noted brown flaky debris in the microwave, dark brown grease with floating debris in the deep fryer, and three sheet pans with encrusted black colored grease buildup. These observations indicate a lack of adherence to professional standards for food safety. Interviews with staff revealed that the microwave had not been cleaned after breakfast use, and the deep fryer, which was supposed to be cleaned weekly, had not been cleaned since frying fish the previous Friday. The sheet pans were acknowledged to have carbon buildup, and there was an ongoing effort to replace them without exceeding the budget. The Dietary Manager and Administrator both recognized the importance of maintaining clean kitchen equipment to prevent foodborne illness, but the facility's practices did not align with these standards.
Failure to Communicate with Residents During Care
Penalty
Summary
The facility failed to treat four residents with respect and dignity, as evidenced by the actions of CNA A, who did not communicate with the residents while providing care. This lack of communication was reported by the residents during a group meeting, where they expressed feelings of disrespect and rudeness from CNA A. The residents involved were able to make themselves understood and had intact cognition, as indicated by their BIMS scores. Despite this, CNA A did not engage with them verbally during care, which was perceived as disrespectful. Resident #5, a female with chronic obstructive pulmonary disease, required assistance with personal hygiene and dressing. Her care plan emphasized the need for communication and cues due to her impaired cognitive function. Resident #7, diagnosed with dementia, also required assistance with personal care and had previously reported CNA A's lack of communication as rude. Resident #10, who had a cerebral infarction, needed moderate assistance and had a care plan that included explaining procedures to her. She reported feeling disrespected by CNA A's lack of communication and an overheard comment. Resident #58, with atherosclerotic heart disease, required substantial assistance and had a care plan that included communication strategies, which were not followed by CNA A. Interviews with staff, including CNA A, revealed a discrepancy between the residents' experiences and CNA A's account of her interactions. CNA A claimed to communicate with residents during care, but the residents' consistent reports of her silence suggest otherwise. The DON and Administrator were aware of past complaints about CNA A's communication, but no further action was taken beyond an initial in-service training. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, which was not upheld in these instances.
Failure to Address Resident Council Grievances on Call Light Response
Penalty
Summary
The facility failed to address and document the grievances and recommendations of the resident council regarding call light response times. Over several months, the Resident Advisory Council Minutes consistently indicated that call lights were not being answered in a timely manner. Despite these repeated concerns being raised in meetings on multiple occasions, there was no documentation of efforts to resolve these issues in the facility's grievance records. Interviews with residents confirmed that they had not received any feedback or resolution regarding their complaints about call light response times. Staff interviews revealed a lack of communication and follow-up on the issue. RN D acknowledged the residents' complaints and reported them to the Assistant Directors of Nursing (ADONs), but no resolution was provided. Both ADON E and the Director of Nursing (DON) stated that they were unaware of any reports from residents or staff about the call light issues. The Administrator admitted awareness of the ongoing problem but failed to provide documentation of grievances or resolutions. The facility's grievance policy requires prompt efforts to resolve grievances, but this was not demonstrated in the handling of the resident council's concerns.
Incomplete DNR Form Lacks Physician's Printed Name
Penalty
Summary
The facility failed to ensure the right to formulate an advanced directive for a resident reviewed for advanced directives. Specifically, the Out-of-Hospital Do Not Resuscitate (OOH-DNR) form for a resident was missing the physician's printed name. This oversight was identified during a record review, which showed that the resident, a female with severe cognitive impairment due to dementia, had an active physician's order for DNR. The comprehensive care plan indicated that the resident's DNR status was to be explained to her or her responsible party, and that she was to be maintained at a level of comfort as ordered by the physician. Interviews with facility staff revealed that the social worker, who was responsible for completing DNRs, acknowledged the missing physician's printed name on the resident's OOH-DNR form. The social worker admitted to conducting random audits but could not specify the date of the last audit, indicating that the missing printed name was overlooked. The facility's administrator stated that DNRs were expected to be filled out completely, including signatures, and emphasized the importance of ensuring residents' code status was up to date to respect their preferences.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #43, which did not reflect her current needs. Resident #43, an elderly female with dementia, muscle weakness, reduced mobility, and anxiety disorder, was identified as being at high risk for falls. Her care plan, last revised on 11/26/2024, included the use of a fall mat at her bedside. However, observations on 01/06/2025 and 01/07/2025 revealed that no fall mat was present, and her order summary dated 01/07/2025 did not indicate the need for a fall mat. Interviews with nursing staff and the administrator confirmed that the care plan was not updated to reflect that Resident #43 no longer required a fall mat due to her inability to transfer or ambulate independently. The deficiency was attributed to a lack of communication and coordination among the nursing staff responsible for updating care plans. RN K and RN L indicated that the MDS team and nursing staff were responsible for updating care plans with any change in condition, but the care plan for Resident #43 was not updated despite discussions in morning meetings. The administrator acknowledged that the nursing staff should have ensured the care plan was current and reflective of Resident #43's needs. This oversight could potentially place Resident #43 at risk of not having her individualized needs met, impacting her quality of life.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs were stored in a locked compartment, accessible only by authorized personnel, for two residents reviewed for medications at their bedside. Resident #34, a male with a diagnosis of COPD, had his nebulizer medication left at his bedside on two occasions. The resident's nebulizer mask was observed to be filled with medication, which he had not yet taken. The nursing staff, including LVN F and LVN G, admitted to setting up the breathing treatment and leaving the room, without ensuring the medication was administered. Resident #34 had not been assessed for self-administration of medication, and the staff acknowledged the importance of not leaving medication at the bedside to prevent misuse and ensure the resident received the prescribed dosage. Resident #59, who has Parkinson's disease, was found with Lamisil, Cortizone-10, and Flonase at his bedside, which were not addressed in his order summary report. The resident was unable to recall the purpose of these medications, and they were reportedly brought by a family member. RN C confirmed that Resident #59 had not been assessed for self-administration, and the medications were removed from his room. The DON emphasized the necessity of completing a self-administration assessment and obtaining an order before allowing medications at the bedside. The facility's policy on medication storage requires that medications be stored safely and securely, accessible only to authorized personnel. The Administrator and other staff members reiterated the importance of storing medications properly to prevent medication errors or misadministration. Despite these policies, the facility failed to comply, resulting in medications being left at the bedside for both residents, which could lead to potential safety risks.
Failure to Provide Consistent Hydration
Penalty
Summary
The facility failed to provide liquids consistent with a resident's needs, specifically for a resident who did not receive her iced tea during a lunch meal. The resident, an elderly female with dementia and unspecified protein-calorie malnutrition, was on a regular diet with ground meat texture and thin/regular liquid consistency. Her comprehensive care plan indicated she was at risk for nutritional problems, including weight loss and dehydration, and required specific dietary interventions. On the observed date, the resident's meal ticket indicated she should receive iced tea, but it was not provided with her lunch tray. During the survey, the RN confirmed the omission of the iced tea and acknowledged its importance in preventing dehydration. The Director of Nursing (DON) and the Administrator both stated their expectations that drinks should be served with meals to ensure proper hydration. The facility's policy on hydration emphasized providing sufficient fluid intake to maintain health, but there was no system in place to monitor drink provision prior to the surveyor's intervention, as this issue had not previously occurred.
Failure to Maintain Proper Food Temperatures and Timely Meal Service
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Observations revealed that food temperatures for various items, including chicken fried chicken patties and mashed potatoes, were held below the required 135 degrees Fahrenheit on the steam table. Despite knowing the correct temperature ranges, the cook did not reheat the food before serving due to being overworked and understaffed. This resulted in meals being served late and at improper temperatures over several days, increasing the risk of foodborne illness for residents. Interviews with the cook and the Dietary Manager (DM) confirmed that the kitchen was understaffed, with the cook working double shifts and the steam table malfunctioning. The DM acknowledged the long-standing issues with the steam table and the stress caused by the lack of staffing. Both the cook and the DM emphasized the importance of serving food at the correct temperatures to ensure resident safety and satisfaction. The Interim Administrator believed that the dietary staff had sufficient staffing and expected them to serve meals on time and at appropriate temperatures. However, the facility's policies on food temperature control and handling of potentially hazardous foods were not followed. The policies required hot foods to be maintained at 140 degrees Fahrenheit or above, which was not achieved due to the staffing and equipment issues in the kitchen.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. During an initial tour observation, two 10-pound packages of ground hamburger meat were found floating in cool water in the sanitization sink of the three-compartment sink. This was not the correct method for thawing meat, which should have been done in a container in the food preparation sink under cool running water. The cook acknowledged the mistake, stating it was done in a hurry because the night staff did not take the meat out to thaw in time for lunch preparation. Additionally, the facility used unpasteurized eggs for sunny-side up and over easy eggs, which were served to residents. The dietary manager (DM) initially believed the eggs were pasteurized but later confirmed they were not after checking with the food supplier. The DM admitted to assuming the eggs were pasteurized when ordering from a new supplier. This oversight posed a risk of food-borne illness to the residents, especially given their susceptibility due to age. The facility also failed to maintain proper food temperatures on the steam table. During an observation, various food items, including chicken fried chicken patties and mashed potatoes, were held at temperatures below the required 135 degrees Fahrenheit. The cook and DM both acknowledged the issue, with the DM stating that the steam table had been problematic for years despite multiple repairs. The cook admitted to not reheating the food before serving due to time constraints. Furthermore, the cook did not properly use the three-compartment sink for washing, rinsing, and sanitizing blender parts, opting to dry them with paper towels instead of air drying, which is the approved method to prevent cross-contamination and ensure sanitation.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for three residents. For Resident #33, the facility did not update the care plan when his antidepressant medication was discontinued. This oversight was confirmed by the MDS Coordinator and the DON, who acknowledged that the care plan should have been updated to reflect the discontinuation of the medication. The failure to update the care plan could have led to the resident receiving the medication after it was discontinued, as the care plan would not have accurate information for those reading it. Resident #4's care plan was not revised after she experienced multiple falls on three separate dates. The comprehensive care plan did not include interventions for these falls, despite the resident being at high risk for falls due to her medical conditions. The DON admitted that interventions should have been added to the care plan for each fall and that the MDS nurses were responsible for updating the care plan. The lack of updates meant that necessary fall interventions were not communicated to the staff, potentially increasing the risk of further falls. For Resident #130, the facility did not update the care plan after the resident experienced falls on two consecutive days. The comprehensive care plan did not include new interventions following these incidents. Interviews with the staff revealed that the floor nurses were not responsible for updating the care plans, and the DON was unaware of the need for updates. The failure to revise the care plan after each fall meant that the staff did not have an accurate picture of the resident's care needs, which could lead to further falls and injuries. The Regional Compliance Nurse confirmed that the DON was responsible for updating the acute care plans, and the lack of updates could result in an inaccurate understanding of the resident's care requirements.
Failure to Provide Routine Hygiene Care
Penalty
Summary
The facility failed to ensure necessary services to maintain grooming and personal hygiene for seven residents. Specifically, the facility did not routinely shower or bathe six residents and failed to shave one resident. These deficiencies were identified through observations, interviews, and record reviews, revealing that the residents did not receive their scheduled baths or showers, and one resident was not shaved due to a missing electric razor. The lack of proper hygiene care could lead to decreased quality of life and self-esteem for the residents involved. Resident #22, a male with pneumonia, stroke, and hemiplegia, reported not receiving a bed bath for three weeks, despite being scheduled for baths three times a week. Similarly, Resident #67, a male with muscle weakness and lung cancer, did not receive his scheduled baths regularly. Both residents expressed feelings of uncleanliness due to missed baths. Additionally, Resident #57, a female with heart failure and anxiety, had inconsistent bath schedules, causing concern for her family members who had to remind staff of her bath days. Resident #36, a female with metabolic encephalopathy and severe obesity, preferred showers but often received bed baths due to staffing issues. Resident #9, a female with dementia and diabetes, also missed her scheduled showers, leading to feelings of uncleanliness. Resident #179, a male with quadriplegia, reported not receiving his scheduled bed baths, resulting in a musty body odor. Lastly, Resident #41, a male with dementia and high blood pressure, was not shaved for a week due to a missing electric razor, which had not been replaced or reported as a grievance. The facility's staff, including CNAs, nurses, and management, acknowledged the issues but failed to ensure consistent hygiene care for the residents.
Failure to Maintain Annual Restraint Training for Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for existing staff, specifically regarding annual restraint training. This deficiency was identified for four employees: two Licensed Vocational Nurses (LVN QQQ and LVN C), a Social Worker (SW), and a Housekeeping Supervisor. All four employees, hired on the same date, did not complete their required annual restraint training. The Corporate HR Specialist confirmed that the last restraint training for these employees was completed in January 2023, and they should have completed their annual training by February 2024. The HR Coordinator was responsible for ensuring the completion of these trainings but was unsure how the oversight occurred, citing time constraints and daily checks that failed to catch the lapse. The Director of Nursing (DON) and the Interim Administrator both expressed that they expected the annual restraint training to be completed and acknowledged that the HR Coordinator was responsible for this task. The facility's policy on New Employee Orientation did not address the requirement for annual training, contributing to the oversight. Interviews with the Corporate HR Specialist, HR Coordinator, DON, and Interim Administrator revealed a lack of clarity and accountability in ensuring the completion of required annual trainings. The HR Coordinator mentioned that staff who did not complete the required trainings were subject to in-service and disciplinary actions, but this process did not prevent the lapse in training. The deficiency places residents at risk for inappropriate use of restraints, as staff without up-to-date training may lack the necessary knowledge to handle restraints properly. The facility's failure to maintain an effective training program highlights a significant gap in their compliance with regulatory requirements.
Failure to Notify Family of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's representative immediately when there was a significant change in the resident's physical status. Specifically, the facility did not inform the family of new areas of shearing, hematoma, bruising, and redness found on the resident. This failure was identified during a review of the resident's records and interviews with staff and family members. The resident, an elderly female with multiple diagnoses including heart failure, atrial fibrillation, and protein-calorie malnutrition, had a care plan that required family notification of any new skin breakdowns. However, the family was not informed of the new skin concerns discovered on a specific date, despite the care plan's directives and the facility's policy on notifying family members of significant changes in status. The resident's weekly skin assessment did not document the new areas of concern, and the progress note from the same date also failed to indicate that the family had been notified. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that although the Medical Director (MD) had assessed the resident and discussed the findings with the nursing staff, there was no documentation to confirm that the family had been informed. The ADON mentioned that if it was not documented, it was not done, highlighting a lapse in communication and documentation. Further interviews with the resident's family confirmed that they were not notified of the new skin issues and only discovered them when assisting the resident themselves. The Interim Administrator acknowledged that the family should have been notified and that it was the nurse's responsibility to do so. The facility's policy on notifying the physician and family of changes in status was not followed, leading to a significant deficiency in communication and care for the resident.
Failure to Provide SNFABN to Resident
Penalty
Summary
The facility failed to ensure that each resident was informed before, or at the time of admission, and periodically during their stay, of services available in the facility and of charges for those services, including services not covered under Medicare/Medicaid. Specifically, the facility did not provide Resident #57 with a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) when she was discharged from skilled services before her covered days were exhausted. This failure was identified during an interview and record review, which revealed that Resident #57, a female with heart failure and weakness, was not informed of her options to continue services at her own expense. The MDS Coordinator admitted to forgetting to provide the SNFABN form because she was filling in for another coordinator who was typically responsible for this task. The Administrator confirmed that the MDS Coordinator and the Business Office Manager (BOM) were responsible for completing the SNFABN forms and emphasized the importance of this process to inform residents or their families about the discharge from skilled services and their right to appeal. The failure to provide the SNFABN form could result in residents not being aware of changes to their provided services and potential out-of-pocket costs.
Failure to Resolve Grievance Regarding Resident's Bathing Schedule
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident who had issues with receiving baths. The resident, an elderly female with multiple diagnoses including heart failure, atrial fibrillation, and anxiety, had a grievance filed by her family member regarding her care, specifically about missed baths. Despite the grievance being marked as resolved, the resident continued to miss scheduled baths on multiple occasions, as confirmed by the resident's family member and facility records. The family member expressed frustration over the inconsistency and lack of follow-up from the facility staff, including the previous administrator's unhelpful response to their concerns. The resident's comprehensive care plan indicated she required assistance with bathing, and her medical records showed she was moderately impaired cognitively but did not refuse care. However, the facility's records revealed that the resident missed several scheduled baths, and there was no documentation of refusal. Interviews with the Director of Nursing (DON) and the Interim Administrator highlighted a lack of oversight and accountability in ensuring the resident received her scheduled baths. The DON admitted to not reviewing reports on completed showers, and the Interim Administrator acknowledged the unresolved nature of the grievance. The facility's grievance policy mandates prompt efforts to resolve grievances, but the continued issues with the resident's bathing schedule indicate a failure to adhere to this policy. The resident's family member had to repeatedly voice concerns, and there was no effective resolution or follow-up, leading to ongoing dissatisfaction and potential risks for the resident. The facility's staff, including the social worker and management, did not adequately address the grievance, resulting in the deficiency noted in the report.
Inaccurate MDS Assessment for Antidepressant Medication
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident status for one of the 24 residents reviewed for MDS assessment accuracy. Specifically, Resident #33's significant change in status MDS assessment inaccurately indicated that the resident had received an antidepressant medication within the 7-day look-back period. However, a review of Resident #33's medication administration records showed that the antidepressant medication, Celexa, had been discontinued prior to the look-back period. This discrepancy was confirmed by the MDS Coordinator, who acknowledged the error and was unsure how it occurred. The Director of Nursing (DON) and the Interim Administrator both stated that they expected MDS assessments to be accurate and that the MDS Coordinator was responsible for ensuring this accuracy. Resident #33, a male with diagnoses including dementia, major depression, and bipolar disorder, had been taking Celexa for depression until it was discontinued on January 27, 2024. Despite this, the MDS assessment dated after this discontinuation inaccurately coded the resident as having received the medication. The facility did not have a specific policy on MDS accuracy but followed the Resident Assessment Instrument (RAI) manual. Interviews with the DON, the RNC, and the Interim Administrator all highlighted the expectation for accurate MDS assessments and the potential risk of inaccurate assessments not reflecting the resident's true care needs.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #70, who was at risk for falls and required a fall mat at the bedside. Despite the care plan and order summary indicating the need for a fall mat, observations on multiple occasions revealed that Resident #70 did not have a fall mat at the bedside. Interviews with staff, including a CNA, LVN, ADON, and DON, confirmed that the fall mat was not in place and that it was the nursing staff's responsibility to ensure its presence. The staff acknowledged the importance of the fall mat in preventing injury and admitted that it might have been moved and not replaced. Resident #70, a [AGE] year-old male with severe cognitive impairment and muscle weakness, was admitted to the facility with a diagnosis of unspecified dementia. The resident's Quarterly MDS assessment indicated a BIMS score of 6, reflecting severe cognitive impairment. The care plan dated 01/19/2024, and the order summary dated 03/02/2024, both specified the need for a fall mat at the bedside. However, during observations on 02/26/2024, the fall mat was missing, and staff interviews revealed a lack of awareness and adherence to the care plan, leading to potential harm for the resident.
Failure to Provide Consistent In-Room Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for one resident. Specifically, the facility did not provide consistent and scheduled in-room activities for a resident with quadriplegia, major depressive disorder, and anxiety disorder. The resident's comprehensive MDS assessment indicated a preference for various activities, but these were not care planned or documented in the resident's electronic health record for the past 30 days. Interviews with the Activity Director (AD) and the Administrator revealed that the AD was responsible for in-room activities but was unable to provide them consistently due to being overburdened with other tasks. The AD admitted to not having a schedule for in-room activities and mentioned that she had requested assistance multiple times without success. The resident expressed feelings of sadness and loneliness due to the lack of in-room activities, which were supposed to provide social interaction and a sense of purpose. The facility's Activity Policy & Procedure Manual indicated that individualized activity programs should be provided regularly, but this was not adhered to in this case.
Failure to Provide Proper Catheter and Incontinent Care
Penalty
Summary
The facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for two residents reviewed for indwelling urinary catheters and incontinent care. Resident #179's urinary catheter was not properly secured to his leg, despite an order to ensure the catheter strap was in place every shift change. During an observation, the resident mentioned that a nurse had informed him that they did not have the supplies to secure the catheter. Interviews with the Administrator, LVN, and DON confirmed that it was the nurses' responsibility to secure the catheter properly to prevent it from being pulled out and causing trauma. Resident #53 was not provided proper incontinent care. The resident, who had severe cognitive impairment and was always incontinent of bowel and bladder, was found to have a bowel movement during an observation. The CNA performed inadequate cleaning, failed to change gloves between dirty and clean tasks, and did not perform hand hygiene. The CNA also failed to cleanse the resident's peri area properly. Interviews with the ADON and DON revealed that the CNA did not follow proper procedures for incontinent care and hand hygiene, which could lead to infections and skin conditions. The facility's policies and procedures for foley catheters and perineal care were not followed, as evidenced by the observations and interviews. The DON and Administrator acknowledged the importance of proper catheter securing and incontinent care to prevent infections. The Regional Compliance Nurse noted that the CNA was nervous during the observation but had passed skills check-offs. The facility's failure to adhere to these policies placed residents at risk for urinary tract infections and other complications.
Failure to Obtain Weekly Weights as Ordered
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, specifically by not obtaining weekly weights as ordered by the physician. Resident #33, a male with diagnoses including dementia, unspecified protein calorie malnutrition, major depression, and bipolar disorder, was identified as at risk for malnutrition. The care plan required weekly weights for at least four weeks or until the resident's weight stabilized. However, the facility did not obtain the resident's weight on two of the specified dates, 02/13/24 and 02/27/24, as documented in the treatment administration record and electronic medical record. Interviews with the Director of Nursing (DON), an LVN, and the Interim Administrator revealed that the responsibility for obtaining weights was assigned to the transport aide and aides or LVNs. The DON emphasized the importance of obtaining weights to monitor nutritional status, while the LVN acknowledged awareness of the missed weights but stated they were overlooked. The Interim Administrator also expected weights to be obtained as ordered but was unsure if a monitoring system was in place. The facility's policy required weights to be documented at admission, readmission, and monthly unless otherwise ordered by the physician or dictated by the resident's condition.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care were provided such care consistent with professional standards of practice. For Resident #6, the facility did not store the nebulizer mask in a bag when it was not in use. During an observation, the nebulizer mask was found laying on top of the nebulizer machine, uncovered. Interviews with the LVN and DON confirmed that the nebulizer mask should have been stored in a bag to prevent infection and ensure cleanliness. The failure to store the nebulizer mask properly could lead to bacterial pneumonia or aspiration due to inhaling bacteria from the uncovered mask. For Resident #227, the facility did not administer oxygen as ordered by the physician. The resident was observed receiving oxygen at 3 liters per minute (l/min) via nasal cannula, while the physician's order specified 2 l/min. Multiple observations confirmed the incorrect oxygen rate, and an interview with the RN revealed that the order had not been updated correctly. The DON and Interim Administrator both acknowledged that the oxygen should have been set at the prescribed rate, and the failure to do so could result in the resident not receiving the appropriate amount of oxygen. These deficiencies highlight the facility's failure to adhere to proper respiratory care protocols, potentially placing residents at risk for respiratory complications. The observations and interviews indicate a lack of compliance with professional standards and physician orders, which could negatively impact the residents' health and quality of care.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Resident #179 was monitored for side effects and behaviors related to the use of multiple psychotropic medications, including Buspirone, Clonazepam, Lexapro, and Trazodone, since his admission. Despite the resident's complex medical history, including quadriplegia, major depressive disorder, and anxiety disorder, there was no documentation of behavior or side effect monitoring in the resident's Treatment Administration Record (TAR) for February 2024. This lack of monitoring was confirmed by the Director of Nursing (DON), who acknowledged the importance of such monitoring to ensure the medications' effectiveness and to prevent adverse side effects. Additionally, the facility failed to ensure that Resident #52's PRN Clonazepam was administered with an adequate indication for its use on two occasions. The resident, who has severe cognitive impairment and a history of anxiety and depression, received Clonazepam without documented behaviors or interventions prior to its administration. The progress notes for these dates did not indicate any specific behaviors or interventions attempted before administering the medication. Interviews with the DON and a Licensed Vocational Nurse (LVN) revealed that non-pharmacological interventions should have been attempted and documented before administering PRN psychotropic medications. The facility's policies and procedures require that all PRN medication orders specify the reason and frequency for use, and that behavior and side effect monitoring be documented. However, these protocols were not followed for Residents #179 and #52, leading to the administration of potentially unnecessary psychotropic medications without proper monitoring. This failure could place residents at risk of adverse side effects and decreased quality of life.
Failure to Secure Nurse Treatment Cart
Penalty
Summary
The facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly. During an observation and interview, a nurse treatment cart was found unlocked and unattended in the hallway. The nurse on duty admitted that the cart should be locked and that she did not know who last accessed it. Keys were also found lying on top of the cart, further compromising security. The nurse acknowledged the importance of keeping the cart locked to prevent residents from accessing potentially harmful medications and supplies. Interviews with the Assistant Director of Nursing (ADON), Administrator (ADM), and Director of Nursing (DON) revealed that they all expected the nurse treatment carts to be locked and the keys to be kept with the nurse. They emphasized the potential harm that could result from unauthorized access to the cart, including residents ingesting or using harmful substances. The facility's Medication Administration policy also required that medication carts be locked after use, but this protocol was not followed in this instance.
Failure to Promote Antibiotic Stewardship
Penalty
Summary
The facility failed to promote antibiotic stewardship by not ensuring the appropriate use of antibiotic therapy and not providing a written rationale when an antibiotic was used despite criteria. Specifically, the facility did not assess Resident #5 using established criteria to determine if her UTI met the criteria for antibiotic use. Additionally, the facility did not ensure an SBAR was performed to indicate a change of condition when Resident #5 exhibited signs and symptoms of a UTI. Resident #5, a female with Alzheimer's disease, was admitted to the facility and had a history of UTIs. Despite having a high range of Escherichia coli in her urine, there were missing assessments and no SBAR completed during the month of February 2024. The resident received antibiotics from February 8 to February 15, 2024, but her antibiotic use was not logged in the antibiotic log for February 2024. Interviews with staff revealed inconsistencies in following the protocol for assessing and documenting antibiotic use. The facility's Antimicrobial Stewardship policy required a complete assessment using established protocols and an SBAR assessment when a resident's condition changed. However, these steps were not followed for Resident #5. The DON and ADON acknowledged the importance of these protocols but were unsure why the required forms and logs were not completed. The failure to follow these protocols could lead to unnecessary antibiotic use and increased antibiotic-resistant infections.
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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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