Cascades At Jacinto Rehab Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 1405 Holland, Houston, Texas 77029
- CMS Provider Number
- 675231
- Inspections on file
- 33
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Cascades At Jacinto Rehab Lp during CMS and state inspections, most recent first.
A resident with aphasia and chronic kidney disease was admitted with documented redness on the right thigh and a physician order for weekly skin assessments. The admission evaluation instructed staff to complete a thorough head-to-toe skin assessment, but the next-day skilled documentation by an LVN indicated the resident had no skin conditions. Later that day, a hospital documented redness and bruising to the hip, back, and leg, and the DON reported to a hospital physician that bruising had been present on admission but had enlarged. Facility CNAs and an LVN gave inconsistent accounts of seeing or not seeing bruising, with one LVN stating she used only bathroom light and that night nurses did not typically perform full skin assessments. The DON and ADON acknowledged that admitting nurses were responsible for initial skin assessments, that staff generally did not measure skin conditions, and that a recent EMR change contributed to incomplete documentation. These actions and omissions resulted in incomplete and inaccurate skin assessment and documentation, contrary to the facility’s Skin Management policy and the physician’s orders.
Surveyors identified that multiple resident rooms were not maintained in a clean, sanitary, and homelike condition, with observations of sticky and heavily stained floors, peeling paint, torn or missing window blinds and privacy curtains, dirty vents, ceiling gaps, brown stains on walls, and dirty clothing left on the floor near full trashcans. Staff, including the Maintenance Director, Administrator, DON, LVNs, and CNAs, reported that rooms are supposed to be cleaned daily by housekeeping with additional monitoring by CNAs, acknowledged that many rooms needed additional cleaning and repairs such as painting and blind replacement, and confirmed that unclean rooms create an unsanitary environment for residents.
Surveyors found that two three-bed rooms in a secure unit were undersized, providing only about 73–74 sq ft per resident instead of the required 80 sq ft. Facility records classified several rooms as three-bed rooms, but the Administrator lacked documentation authorizing three beds and acknowledged the 80 sq ft per-resident requirement. The Maintenance Director measured the rooms, confirmed the insufficient space, and reported being unaware of the exact square footage requirement, noting potential risks such as falls, trips, clutter, and limited evacuation space.
The facility did not maintain an effective pest control program, resulting in live flies and gnats being observed in a hallway, conference room, and a shared room of two residents with severe cognitive impairment. Staff and residents reported ongoing issues with pests, and facility records showed only monthly pest control services, with staff expressing concerns about their effectiveness.
A resident with a history of elopement and cognitive impairment exited the secured unit through a window that lacked an alarm, despite being identified as a high-risk wanderer and having a care plan for monitoring and diversional interventions. Staff discovered the resident missing during meal service, and the window was found open with the screen pushed out. The resident was later located at a previous residence, but staff were unable to assess for injury after the incident.
A resident with chronic kidney disease and an indwelling urinary catheter was found with a urine collection bag positioned above bladder level after being transferred to a recliner. The CNA responsible admitted to not placing the bag correctly due to rushing, despite knowing the proper procedure. The resident was dependent on staff for most ADLs and was being treated for a UTI at the time. Facility policy required the drainage bag to be kept below the bladder to prevent infection.
A resident with a history of major depressive disorder and previous suicide attempts was found with a call light wire around his neck, indicating a possible suicide attempt. Despite the severity of the situation, the facility failed to report the incident to the state agency in a timely manner, as required by their policy. The resident was sent to the hospital, but the facility's DON and Administrator were not immediately informed, delaying the reporting process. This failure to adhere to policies and procedures could place residents at risk of continued or unrecognized mistreatment.
A resident with a history of depression and previous suicide attempt was found with a call light wire around his neck, indicating a possible suicide attempt. The facility staff removed the wire and called 911, but failed to report the incident to the state agency within the required 24-hour timeframe. Interviews revealed no prior signs of suicidal ideation, and the delay in reporting was due to the DON and Administrator not being immediately informed.
The facility failed to maintain RN coverage for at least 8 consecutive hours on three specific days, potentially risking missed nursing assessments and care. Record reviews showed no RN was present, and the DON worked limited hours on those days. Interviews confirmed the requirement for RN presence, and the facility's policy mandates RN services daily.
A LTC facility experienced a 17% medication error rate involving two residents and two staff members. Errors included crushing medications that should not be crushed, administering another resident's medication, and using the wrong type of flush for IV maintenance. The involved residents had varying cognitive impairments and medical conditions, and the errors were acknowledged by the facility's DON and Administrator.
Two residents experienced a lack of privacy during medical procedures. An LVN administered medication via g-tube to a resident without closing the privacy curtain, while another LVN performed an IV flush in the hallway. Both actions were contrary to facility policy on resident dignity and privacy.
Two LVNs failed to follow infection control protocols in a facility, with one not wearing appropriate PPE while administering medication via a PEG tube to a resident on enhanced barrier precautions, and another not donning a gown while performing an IV flush on a resident with an IV site. Both residents had specific care plans requiring enhanced barrier precautions, which were not followed, potentially risking infection.
A facility failed to follow up on a Dietitian's recommendations for a resident with severe weight loss, who had a history of cancer, malnutrition, and other health issues. Despite the resident's reported good oral intake, her weight continued to decline. The Dietitian's recommendations for liquid protein and supplements were not implemented due to a communication breakdown and format issues in the submission of recommendations. This oversight led to the resident not receiving necessary nutritional support.
A medication aide in an LTC facility administered Gabapentin intended for one resident to another due to a failure to verify the resident's name during preparation. The error involved a resident with severe cognitive impairment and multiple health issues. The facility's policy requires checking medication details three times, which was not adhered to, leading to the error.
Failure to Perform and Document Accurate Skin Assessments for Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff had and used appropriate competencies to complete accurate and thorough skin assessments for a newly admitted resident, as required by physician orders and facility policy. The resident was an older adult male admitted with diagnoses including aphasia following cerebral infarction and anemia in chronic kidney disease. On admission, the Clinical Evaluation documented redness on the front and rear right thigh and directed staff to complete a thorough head-to-toe skin assessment and identify all abnormalities. A physician order dated the day of admission required weekly skin assessments starting the following day. Progress notes confirmed the resident’s admission and that he was to be transferred to a local hospital the next morning for feeding tube replacement. On the morning after admission, the Daily Skilled Documentation completed by LVN C indicated “no” to the question asking whether the resident had any skin conditions, despite the prior documentation of redness to the right thigh and the physician’s order for skin assessments. Later that same day, documentation from the local hospital recorded skin integrity findings of redness and bruising to the right hip, back, and leg. A subsequent progress note from the facility documented that the DON spoke with a hospital physician who reported bruising on the resident’s leg that was getting progressively worse; the DON stated to the physician that the bruising had been present on admission but was not as large. However, there was no complete or accurate skin assessment in the facility record reflecting the presence, description, or progression of this bruising. Interviews with facility staff showed inconsistent recognition and documentation of the resident’s skin condition and revealed gaps in assessment practices. LVN C, who cared for the resident on the morning shift and transferred him to the hospital, recalled excoriation on the bottom and groin and a healed great toe amputation but denied seeing any large bruising. CNA C, who changed the resident’s brief overnight, reported not seeing any bruising and noted the resident did not express pain when turned. LVN B, who had the resident on the night shift, stated she observed a previous injury on the leg that she thought was a bruise or discoloration but could not recall which side; she also stated she only used light from the bathroom to avoid waking the resident and that night nurses did not typically perform full skin assessments. The ADON and DON confirmed that admitting nurses were responsible for initial skin assessments, that staff generally did not measure bruises or other skin conditions, and that documentation practices were affected by a recent change in the electronic medical record system. The facility’s Skin Management policy required identification, assessment, and ongoing monitoring of individuals at risk for skin compromise, but the resident’s records and staff interviews demonstrated that these assessments were not completed completely and correctly for this resident. Observation at the local hospital two days after admission showed a large red and purplish bruise starting above the right hip and extending down the right thigh, measuring 15 inches in length. Hospital nursing staff confirmed the presence of bruising but did not have measurements from the time of transfer. Facility leadership acknowledged that skin conditions, including bruises that were getting larger, should be documented and that inaccurate or incomplete skin assessment documentation could allow conditions to worsen. Despite this, the resident’s facility documentation did not accurately reflect the bruising described by the hospital physician and observed later, nor did it align with the facility’s own policy requiring thorough skin assessments and ongoing monitoring. This combination of incomplete assessment, inconsistent staff observations, and inadequate documentation constituted the failure to ensure sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable well-being of the resident. The report explicitly states that the facility failed to ensure that skin assessments were completed completely and correctly for this resident. The DON and ADON described that nurses generally did not measure skin conditions and relied on descriptive documentation, and that the transition to a new computer charting system contributed to confusion about how to document existing versus new skin issues. The Administrator further noted that features needed for documentation were still being added to the electronic medical record and that staff needed education on the new system. These statements, combined with the lack of accurate skin assessment entries and the discrepancy between facility records and hospital findings, demonstrate that the nursing staff did not consistently apply the competencies and skills necessary to assess, evaluate, plan, and implement care related to the resident’s skin condition as required by the facility’s Skin Management policy and the physician’s orders.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide housekeeping and maintenance services necessary to maintain a clean, sanitary, safe, and homelike environment in multiple resident rooms. Surveyors observed that several rooms had floors with thick, dark, dirty stains along the edges and corners, and some floors were described as dirty and sticky. In one room, the bed was positioned close to a torn window blind, and in other rooms, window blinds were torn, damaged, or missing entirely. One room lacked both a window blind and a privacy curtain, and the wall by the window had brown stains on the bottom. Additional observations included multiple dirty resident clothing items on the floor near a full dirty trashcan, holes or gaps in the ceiling, and an air vent with thick black dirt on the vents. The bathroom floor in one room had dark stains along the corners and behind the toilet. In another room, the base of the wall near the entrance was peeled off with brown liquid around it. Walls in multiple rooms were in poor condition with paint visibly peeling off in several areas, and staff interviews confirmed that many resident rooms needed painting and that window blinds were torn and required replacement. Staff interviews revealed that housekeeping was expected to clean resident rooms once daily and as needed, with CNAs responsible for monitoring rooms after housekeeping rounds and picking up dirty laundry. The Maintenance Director stated that she checked each room daily for hazards and acknowledged that the rooms observed did not feel homelike and that the black substance on the vent and the ceiling gap were not acceptable. The Administrator, DON, LVNs, and a CNA all acknowledged that resident rooms should be clean, safe, and homelike, and confirmed that unclean rooms would be unsanitary for residents. The Administrator also acknowledged that there had been instances where cleaning duties were not completed as expected and that environmental issues remained due to the age of the building and competing priorities, despite ongoing efforts.
Noncompliant Room Square Footage in Multi-Occupancy Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in two multiple-occupancy rooms. Form 3740 Bed Classifications, signed by the Administrator, listed rooms #311, #312, #313, #314, #315, and #316 as three-bed rooms. During surveyor review, rooms #311 and #314 in the secure unit were measured by the Maintenance Director and found to be approximately 220–221.3 square feet each, which equated to about 73–74 square feet per resident when occupied by three residents. The Administrator acknowledged that each resident was required to have 80 square feet and that these rooms did not meet that standard. During interviews, the Administrator stated she did not have documentation showing that three beds were allowed in these rooms and reported that the corporate office had previously informed her that a waiver was not needed. The Maintenance Director reported being unsure of the required amount of space per resident and stated that no concerns had been brought to her about room size or number of beds. She identified that risks associated with inadequate space could include falls, trips, clutter, and insufficient space for evacuation. These observations, interviews, and record reviews established that rooms #311 and #314 did not meet the minimum square footage requirement per resident.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live flies and gnats in one of the hallways, a conference room, and a shared resident room. Observations revealed two gnats in the conference room and one gnat in the hallway outside the conference room. In the shared room of two residents, two flies were observed, with one fly landing on a resident's linen and another on a bedside table. One of the residents confirmed seeing flies in the room regularly but had not reported it to staff. Both residents in the affected room had severe cognitive impairment, as indicated by their BIMS scores of 3, and one had a principal diagnosis of unspecified psychosis while the other had chronic obstructive pulmonary disease. Staff interviews revealed that the pest control company serviced the facility monthly, but staff, including the Maintenance Director and DON, expressed concerns about the effectiveness of the pest control measures. The Maintenance Director reported frequent sightings of gnats and roaches and had unsuccessfully requested increased pest control visits. Facility records showed monthly pest control invoices for ant, spider, and roach prevention, but there was no detailed documentation of the treatment provided for the most recent visit. The facility's pest control policy required an ongoing program to keep the building free of insects and rodents, but the presence of pests in resident and common areas indicated that this policy was not effectively implemented at the time of the survey.
Failure to Prevent Elopement from Secured Unit
Penalty
Summary
A deficiency occurred when a resident with a history of elopement and cognitive impairment was able to leave the secured unit of the facility through a window. The resident had previously attempted to escape through a window at another facility and was admitted to the secured unit based on family input and prior history. Despite being identified as a high-risk wanderer and having a care plan that included interventions such as monitoring during rounds and diversional activities, the resident was able to open a window and exit the facility undetected by staff. On the day of the incident, staff discovered the resident missing during meal tray distribution and found the window in the resident's room open. There were no alarms on the windows in the secured unit, and the window screen had been pushed out. Staff initiated the elopement protocol and notified law enforcement, but there were no witnesses to the resident leaving. The resident was later located at a previous residence by a neighbor, but staff were unable to assess the resident for possible injury after the elopement. Interviews with facility staff revealed that the resident did not display exit-seeking behaviors prior to the incident and was considered quiet and pleasant. The decision to place the resident in the secured unit was based on prior elopement attempts and family recommendations, rather than solely on cognitive assessment scores. The facility's elopement prevention policies required monitoring and specific interventions for high-risk residents, but the lack of window alarms and the ability for windows to be opened wide enough for egress contributed to the resident's ability to elope.
Improper Positioning of Urine Collection Bag for Catheterized Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to position the urine collection bag of an indwelling urinary catheter below the bladder of a resident after transferring the resident from bed to a recliner. The urine collection bag was observed hooked on the armrest of the recliner, which was above the resident's bladder level. This was confirmed by a licensed vocational nurse (LVN) who stated that the bag should not be at or above the bladder due to the risk of infection from potential backflow of urine. The CNA acknowledged awareness of the correct procedure but admitted to rushing and leaving the bag in the wrong position. The resident involved had chronic kidney disease, urinary retention, and was dependent on staff for most activities of daily living. The care plan included goals to prevent infection but did not specify the need to keep the urinary catheter bag below bladder level. The resident was being treated for a urinary tract infection at the time of the incident. Facility policy required that the drainage bag be positioned lower than the bladder at all times to prevent complications, including urinary tract infections.
Failure to Report and Prevent Abuse in Resident with Suicidal Ideation
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and theft, specifically in the case of a resident who was found with a call light wire wrapped around his neck, indicating a possible suicide attempt. The incident occurred when a CNA discovered the resident in this state and called for help. Despite the severity of the situation, the facility did not report the incident to the state agency in a timely manner, as required by their policy. The resident involved was a male with a history of major depressive disorder, anxiety, Alzheimer's disease, and a previous suicide attempt. He was admitted to the facility from a behavioral hospital and was care-planned for suicidal ideation. On the night of the incident, the resident was found lethargic with ligature marks on his neck, and he was subsequently sent to the hospital. Interviews with staff revealed that the resident had not shown signs of suicidal ideation prior to the incident, and there was a lack of communication regarding his previous suicide attempt. The facility's Director of Nursing (DON) and Administrator were not immediately informed of the incident, which delayed the reporting process. The DON believed that the incident did not meet the criteria for immediate reporting under new state guidelines, as the resident did not have an injury of unknown origin and did not expire at the facility. However, the Administrator expressed concern about the lack of timely reporting, emphasizing the importance of reporting unusual incidents to protect residents. The facility's failure to adhere to its policies and procedures for reporting abuse and neglect could place residents at risk of continued or unrecognized mistreatment.
Failure to Timely Report Possible Suicide Attempt
Penalty
Summary
The facility failed to report an alleged violation involving a possible suicide attempt by a resident within the required 24-hour timeframe to the state agency. The incident involved a resident who was found in bed with a call light wire wrapped around his neck, which was considered a possible suicide attempt. Despite the seriousness of the situation, the facility did not notify the state agency until the following day, which is a violation of the reporting requirements. The resident involved was a male with a history of major depressive disorder, anxiety, Alzheimer's disease, and a previous suicide attempt. On the night of the incident, a CNA found the resident with the call light wire around his neck and called for help. The resident was lethargic but responsive to verbal and touch stimuli. The staff removed the wire, assessed the resident's condition, and called 911. The resident was then transported to the hospital for further evaluation. Interviews with facility staff revealed that there were no prior indications of suicidal ideation from the resident, and he was generally described as quiet and polite. The Director of Nursing (DON) and the Administrator were not immediately informed of the incident, which contributed to the delay in reporting to the state agency. The facility's policy requires immediate reporting of such incidents to the administrator and other officials according to state law, which was not adhered to in this case.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, on three specific days: 9/21/24, 9/29/24, and 10/20/24. Record reviews indicated that no RN signed in or was scheduled on these days. The Director of Nursing (DON) worked only 4.6 hours on 9/21/24, did not work on 9/29/24, and worked 6.93 hours on 10/20/24. This lack of RN coverage could potentially place residents at risk of missed nursing assessments, interventions, care, and treatment. Interviews with the DON and the Administrator confirmed the requirement for an RN to be present for 8 consecutive hours daily. The DON typically covered RN duties when no other RN was available, but was unsure why coverage was lacking on the specified days. The Administrator acknowledged the absence of RN coverage and mentioned that the DON had been working weekends to fill this gap until a new RN was hired for weekend shifts. The facility's policy mandates RN services for at least 8 consecutive hours every day, highlighting the importance of RN presence for tasks such as direct supervision, incident reporting, and managing IV and PICC lines.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 17% error rate. This was based on 5 errors out of 29 opportunities involving two residents and two staff members. One medication aide, MA A, crushed and administered medications that should not be crushed, including Divalproex DR and Oxybutynin ER, to a resident. Additionally, MA A administered another resident's Sertraline to the same resident and used chewable Aspirin instead of the prescribed enteric-coated Aspirin. The resident involved in these errors was a male with severe cognitive impairment, diagnosed with Alzheimer's disease, major depressive disorder, and other conditions. His care plan required medications to be administered as ordered, but MA A failed to adhere to these orders. MA A admitted to using another resident's medication due to unavailability and was under the impression that borrowing medication was acceptable for one-time use. The Director of Nursing (DON) and Administrator confirmed that this practice was against facility policy. Another error involved LVN B, who administered a Heparin lock flush instead of the prescribed normal saline flush to a different resident. This resident had intact cognition and was on IV antibiotics for an acute infection. LVN B mistakenly used the Heparin flush, believing it was normal saline, and later realized the error. The DON and the resident's physician were notified, and although the physician stated there was no harm, the error was acknowledged as a deviation from the prescribed care.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure residents' right to privacy during personal care for two residents. In the first instance, a Licensed Vocational Nurse (LVN A) did not close the privacy curtain between Resident #56 and her roommate while administering medication via a gastrostomy tube. This oversight occurred despite the presence of the roommate in the room, and LVN A acknowledged forgetting to pull the curtain due to the roommate's anxiety when the curtain was closed. Resident #56, a female with severe cognitive impairment and multiple medical conditions, including a gastrostomy infection and hemiplegia, was dependent on staff for activities of daily living and tube feeding. In the second instance, LVN B administered an intravenous (IV) flush to Resident #20 in the middle of the hallway, with other residents and staff present. Resident #20, a male with intact cognition and a diagnosis of bipolar disorder and major depressive disorder, was receiving IV antibiotics for an acute infection. LVN B stated that she typically administered flushes in the hallway or near the nursing station without issue, although she did educate the resident on privacy. The Director of Nursing (DON) and the Administrator both emphasized the importance of privacy and dignity, stating that such procedures should not occur in the hallway.
Inadequate Infection Control Practices by LVNs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A and LVN B. LVN A did not wear the appropriate personal protective equipment (PPE) when administering medication via a PEG tube to a resident who was on enhanced barrier precautions. Despite the presence of a sign on the resident's door indicating the need for gloves and a gown, LVN A only donned gloves and used an oxygen key from her pocket to declog the resident's g-tube, which could introduce infection. The resident had a history of severe cognitive impairment and required tube feeding due to dysphagia. Similarly, LVN B did not adhere to the facility's infection control protocols when administering an IV flush to another resident who was also on enhanced barrier precautions. LVN B only wore gloves and did not don a gown, despite the resident's care plan indicating the need for full PPE, including a face mask, gown, and gloves, due to the presence of an IV site. The resident had intact cognition and required assistance with activities of daily living. Interviews with the Director of Nursing (DON) and the facility's Administrator revealed that the staff had been educated on enhanced barrier precautions, which required the use of gloves and gowns during high-contact care activities. However, both LVNs failed to comply with these protocols, potentially placing residents at risk of infection. The facility's policies on enhanced barrier precautions and medication administration emphasized the importance of following established infection control procedures, which were not adhered to in these instances.
Failure to Implement Dietitian's Recommendations for Nutritional Support
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status, as evidenced by the lack of follow-up on the Registered Dietitian's recommendations for addressing severe weight loss. The resident, a female with a history of malignant neoplasm of the pancreas, moderate protein-calorie malnutrition, type 2 diabetes, and heart failure, experienced significant weight loss over several months. Despite the resident's oral intake being reported as generally 100% of meals, her weight continued to decline, indicating a failure to implement necessary dietary interventions. The Registered Dietitian recommended liquid protein and a 2.0 supplement to support the resident's nutritional intake. However, these recommendations were not followed up on by the facility's Director of Nursing (DON), as they were not submitted in the expected individualized form but rather on a spreadsheet. The DON admitted to missing these recommendations due to the format in which they were received and did not ensure that the necessary physician's orders were obtained to implement the dietary changes. Interviews with facility staff, including the DON and the Administrator, revealed a breakdown in communication and adherence to the facility's procedures for handling dietary recommendations. The Administrator acknowledged that the Dietitian did not follow the facility's system for submitting recommendations, and the DON failed to follow up on the recommendations due to the format discrepancy. This oversight resulted in the resident not receiving the recommended nutritional supplements, potentially impacting her health status.
Medication Administration Error Due to Verification Lapse
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications, as evidenced by an incident involving the administration of Gabapentin. A medication aide (MA K) mistakenly administered Gabapentin intended for one resident to another resident. This error occurred because MA K did not verify the resident's name while preparing the medications, despite being trained to check the right resident, medication name, dose, and route. The medications for the two residents were stored next to each other, which contributed to the mix-up. Resident #2, a female with severe cognitive impairment and multiple diagnoses including malignant neoplasm of the pancreas, pain, type 2 diabetes, and heart failure, received the incorrect medication. The Director of Nursing (DON) and the Administrator both emphasized the importance of verifying the resident's name and medication details to prevent such errors. The facility's policy on administering medications requires checking the label three times to ensure the right resident, medication, dosage, time, and method of administration, which was not followed in this instance.
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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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