Center At Zaragoza, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 12660 Pebble Hills Blvd., El Paso, Texas 79938
- CMS Provider Number
- 745005
- Inspections on file
- 18
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Center At Zaragoza, Llc during CMS and state inspections, most recent first.
An LVN independently removed a resident’s PICC line used for IV antibiotics, despite facility policy and Texas Board of Nursing guidance that only an RN may perform PICC insertion or removal. The resident, who had multiple cardiac conditions and moderate cognitive impairment, reported that the line was removed at the facility and denied pain or complications, and surveyors observed an intact, non-infected site. Documentation and staff interviews confirmed that the LVN performed the removal alone under a provider discontinue order, while the RN, ADON, DON, and Administrator all acknowledged that PICC removal is outside LVN scope and should be done by an RN.
A nurse failed to immediately notify a physician after observing blood-tinged urine and low output in a resident with a catheter. The issue was only reported to the physician after a family member raised concerns during the next shift, resulting in a delay in care.
A CNA did not perform proper hand hygiene or change gloves as required while providing incontinence care to a resident with multiple health conditions, including a history of UTI and bacteremia. The CNA wore gloves into the room, failed to change visibly soiled gloves, and did not wash hands before or after care, contrary to facility policy and infection control standards.
Three residents with significant physical or cognitive impairments did not have their call lights within reach, despite care plans and facility policy requiring this accommodation. Observations showed call lights on the floor or out of reach, and staff confirmed the deficiency and its risks. Residents were unable to request assistance as needed, relying on staff rounds or attempting to call out for help.
Two residents with severe cognitive impairment and multiple medical conditions did not receive proper assistance with fingernail care, resulting in dirty nails with visible debris. Staff interviews confirmed that nail care was the responsibility of nursing staff and CNAs, but there was no monitoring system in place to ensure this care was provided, despite facility policy requiring regular ADL assistance.
Staff failed to properly store and dispose of topical medications, leaving ointments in clear measuring cups exposed and accessible at the bedsides of two residents. Both residents required barrier creams for skin conditions, and staff interviews confirmed that medications should have been disposed of immediately after use. The facility did not have a policy for supervising or disposing of medications after administration.
Surveyors identified failures in food storage and sanitation, including unsealed containers of rice and soup, a torn bag of carrots, improperly sealed frozen turkey patties, a dirty container of tomato sauce, and undated frozen pastries. Staff interviews confirmed these practices did not follow facility policy, which requires all food to be sealed, cleaned, and dated to prevent contamination.
A resident receiving continuous oxygen therapy did not have an oxygen sign posted outside her room, despite staff and leadership acknowledging the importance of this practice for safety and monitoring. The facility lacked a written policy requiring oxygen signs, and the deficiency was confirmed through observation and staff interviews.
A resident with multiple medical conditions did not receive Megestrol Acetate as ordered for several days, and there was no documentation or rationale for the missed doses in the medical record. Staff interviews confirmed that medication aides and nurses did not follow procedures for documenting missed medications or notifying appropriate personnel.
A facility failed to implement a comprehensive care plan for a resident, omitting focus areas for bed rail use and the reassignment of a CNA involved in an incident. The resident, with anxiety and osteoporosis, had no care plan focus on bed rails despite an injury during care. Interviews revealed care plans did not reflect the resident's needs, risking inadequate care.
A resident in a long-term care facility was not assessed for the risk of entrapment from a bed rail before its installation, leading to an incident where the resident injured her wrist. The resident, who was dependent on staff for daily activities, did not have a Bed Transfer Bar Evaluation Assessment, and her care plans lacked a focus on bed rail use. Facility staff interviews revealed no policy for conducting such assessments, potentially placing residents at risk of injury from inappropriate enablers.
Two residents experienced breaches of privacy during personal care in the facility. A staff member failed to close blinds while weighing a resident, and a CNA left a room door open, exposing another resident's private area. Both incidents were acknowledged by staff, highlighting the need for privacy during care.
A facility failed to accurately reflect a resident's use of bed rails in the MDS assessment, despite orders indicating their use for bed mobility. The resident's care plans also lacked focus on bed rail use, and interviews with the DON and MDS Coordinator revealed a lack of awareness regarding the coding and associated risks. This oversight could risk inadequate care for the resident.
A facility failed to ensure a safe environment by not following proper procedures for using a mechanical lift. A staff coordinator weighed a resident using a mechanical lift without locking the brakes and without a second staff member, contrary to facility policy. The resident, with a history of falls and various medical conditions, required a Hoyer lift with two aides for transfers. The facility's policy mandates two staff members for mechanical lift use to ensure safety.
A resident with a Foley catheter was at risk for infection due to improper catheter care. The catheter bag was observed to be full, with urine backing up into the tubing, and the resident reported infrequent drainage by staff. Interviews with facility staff revealed a lack of adherence to catheter care protocols, including timely emptying of the catheter bag and reporting issues to nursing staff.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed improper food storage, expired food, and unclean food preparation areas. The Dietary Manager was observed without a beard guard, and there was no tracking system for cleaning tasks, placing residents at risk of foodborne illnesses.
The facility failed to develop and implement baseline care plans for three residents, leading to unmet dietary preferences, unaddressed diabetes management, and lack of necessary pressure reducing boots. Staff were unaware of critical medical needs, and residents were not involved in the care planning process.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific medical needs, including a tracheostomy, a vegetarian diet, and Type 2 Diabetes Mellitus.
A resident with severe osteoporosis and multiple fractures did not receive timely wound care for a knee wound, despite the facility's policy requiring comprehensive skin evaluations and adherence to treatment orders. The wound was first documented but not treated until several days later, with inconsistent care provided thereafter.
The facility failed to label a resident's enteral feeding formula bag with necessary information, risking incorrect feeding. The resident, who was on continuous feedings with Jevity 1.2 via a g-tube, had unlabeled feeding and water bags, which was confirmed by the LVN and DON.
LVN Removed PICC Line Outside Scope of Practice
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses possessed and adhered to the appropriate competencies and scope of practice for resident care, specifically related to the removal of a Peripherally Inserted Central Catheter (PICC) line. A male resident with chronic systolic congestive heart failure, chronic atrial fibrillation, ischemic cardiomyopathy with pacemaker, venous insufficiency, and a history of pulmonary thromboembolism was admitted and had an active care plan for completion of an antibiotic regimen via PICC line. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 11. The care plan documented the use of a PICC line for antibiotic therapy, and the resident later reported that his PICC line had been removed at the facility a couple of weeks prior to the survey. On the date of the incident, a progress note completed by an LVN documented that the resident’s midline was discontinued per MD order using aseptic technique, with the catheter measured, tip intact, pressure applied, and a pressure dressing placed. The LVN documented that the resident tolerated the procedure well and was resting comfortably afterward. During interview, the resident confirmed that he had a PICC line that was removed at the facility, did not recall who was present during the removal, and denied pain or discomfort during or after the procedure. Observation of the site by surveyors showed no swelling, signs of infection, redness, or scabbing at the extraction site. Interviews with staff established that the LVN removed the PICC line independently, without RN presence or oversight, despite acknowledging that LVNs at the facility were only allowed to change PICC dressings and that PICC removal was not within LVN scope of practice. The LVN stated that RNs were responsible for pulling PICC lines and that removal required a provider order. The RN, ADON, DON, and Administrator each stated that only an RN could remove a PICC line per facility policy and Texas Board of Nursing standards, and that LVNs were not allowed to remove PICC lines. The ADON reported learning of the incident by reviewing progress notes and confirmed that the LVN had removed the line under discontinue orders from the NP, with no RN present. The DON confirmed she became aware that the LVN had removed the PICC line and informed the LVN that this was outside LVN scope of practice. Review of the Texas Board of Nursing position statement showed that insertion and removal of PICC lines or midline catheters is beyond the scope of practice for LVNs, confirming that the LVN practiced outside her scope when she removed the resident’s PICC line.
Failure to Immediately Notify Physician of Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical condition. Specifically, a nurse observed that a resident with a history of urinary retention and benign prostatic hyperplasia, who had an indwelling catheter, had red-tinged urine and low output during a shift. The nurse documented the finding and intended to notify the oncoming shift, but did not immediately inform the physician. The next shift was notified by a family member about continued issues with the catheter, including clots and dark red urine, at which point the physician was contacted and further interventions were ordered. Interviews with staff confirmed that changes in urine color and output should be promptly reported to the physician, and that it is the nurse's responsibility to ensure timely notification of any change in condition. The facility's policy also requires immediate physician notification for such changes. Documentation and staff statements indicated that the initial nurse did not follow this protocol, resulting in a delay in physician notification regarding the resident's change in condition.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to follow proper infection control procedures while providing incontinence care to a 73-year-old female resident with a history of urinary tract infection, bacteremia, abdominal pain, pancreatic cancer, and muscle weakness. The resident required moderate assistance with activities of daily living and was always incontinent of bowel and bladder. During observed care, CNA A did not wash her hands before donning gloves, put on gloves in the hallway, and proceeded to remove a soiled brief and clean the resident without changing gloves, even when the gloves became visibly soiled with urine and fecal matter. CNA A also failed to perform hand hygiene or change gloves before retrieving and applying a clean brief, and did not wash her hands after removing gloves or before exiting the resident's room. In interviews, CNA A acknowledged awareness of the correct procedures, stating she should have washed her hands before starting care and changed gloves during care, but attributed her failure to not paying attention. The Director of Nursing (DON) confirmed that staff are expected to follow facility protocols, including hand washing and glove changes as needed, and that infection control training is provided annually. Review of the facility's hand hygiene policy confirmed the requirement for hand washing before care, glove changes as needed, and hand hygiene after glove removal.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, as required by their care plans and the facility's own policy. Observations and interviews revealed that one resident was found lying in bed with the call light on the floor, out of reach and not visible to her. She stated she needed assistance to get out of bed and would have to wait for staff to check on her if she needed help, as she could not reach or see the call light. Another resident was observed in bed with the call light on the floor, three feet away, and he was unaware it had fallen. He stated he could not get up and would have to wait for staff rounds or try to shout for help in an emergency. A third resident, who was dependent for all self-care and unable to move independently in his wheelchair, was observed with the call light placed on the bed frame on the opposite side of the room, out of his reach. Staff interviews confirmed that the call light was not accessible to him and acknowledged the risk of injury or unmet needs when call lights are not within reach. Multiple staff members, including CNAs, RNs, the ADON, and the DON, stated that call lights are to be kept within reach of residents at all times, and that staff are responsible for monitoring their placement during regular rounds. Record reviews for all three residents showed significant physical and/or cognitive impairments, with care plans specifically directing that call lights be kept within reach to accommodate their needs and reduce fall risk. Despite these documented requirements and staff awareness, the facility did not ensure compliance, resulting in residents being unable to request assistance as needed. The facility's policy also required call lights to be within easy reach for residents in bed or confined to a chair, which was not followed in these cases.
Failure to Provide ADL Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically in the area of fingernail care, for two residents who required substantial or maximal assistance due to severe cognitive impairment and other medical conditions. Observations revealed that both residents had dirty fingernails with visible debris, and one resident expressed a desire for his nails to be cleaned and cut. Record reviews indicated that both residents had care plans and assessments documenting their need for assistance with personal hygiene, including grooming and nail care, due to diagnoses such as Alzheimer's disease, dementia, diabetes, and muscle weakness. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed that nursing staff and CNAs were responsible for monitoring and providing nail care, with nurses specifically assigned to diabetic residents. However, it was acknowledged that there was no system in place to monitor or ensure that nail care services were consistently provided. Facility policy required assistance with ADLs, including grooming, every shift as appropriate, but this was not followed for the two residents identified in the report.
Failure to Secure and Dispose of Topical Medications at Bedside
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were stored in locked compartments and only accessed by authorized personnel, as required. During observations, two residents were found to have clear measuring cups containing ointments left exposed and within reach at their bedsides. One resident had a cup with zinc oxide pomade and a tongue depressor, while another had a cup with an unknown pink ointment. Both items were accessible to other residents and had not been properly disposed of after use. Record reviews indicated that both residents had medical conditions requiring topical treatments, such as pressure ulcers and skin breakdown, with physician orders for the application of barrier creams. Interviews with staff, including CNAs, LVNs, RNs, and the DON, confirmed that the standard procedure was to apply the medication and immediately dispose of any remaining product. Staff acknowledged that leaving ointments at the bedside was not in accordance with facility protocols and could result in contamination or misuse. Further interviews revealed that staff could not recall recent training on medication storage and supervision, and the facility lacked a policy outlining procedures for supervising medications and disposing of them after administration. The failure to properly store and dispose of medications resulted in medications being left unattended and accessible at residents' bedsides.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and handling of food items. Specifically, containers of rice and chicken soup in the walk-in refrigerator were found with lids slightly open, and a bag of carrots was torn, exposing the contents to air. In the walk-in freezer, a bag of frozen turkey patties was not properly sealed, a container of frozen tomato sauce had dried drippings and residue around the lid, and bags of churros and donuts were undated. These observations were corroborated by interviews with the Executive Chef and a cook, both of whom confirmed that all food containers should be sealed, cleaned, and dated according to facility policy to prevent cross contamination and preserve freshness. The facility's Food Storage Policy requires all frozen food items to be properly sealed and dated, and fresh fruits and vegetables to be stored in bins, cartons, or bags. The staff interviewed acknowledged that the observed practices did not align with their training or facility policy, and that such lapses could result in food not being fresh or potentially contaminated. No specific residents or patient medical histories were mentioned in the report, and the deficiency was limited to the kitchen's food storage and sanitation practices.
Failure to Post Oxygen Sign for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy, as evidenced by the absence of an oxygen sign posted outside the resident's room. The resident, a cognitively intact female with a history of asthma, COPD, or chronic lung disease, was observed receiving continuous oxygen via nasal cannula in her room. Despite the care plan specifying the use of supplemental oxygen and the need for monitoring, there was no visible indication outside the room to alert staff or visitors to the presence of oxygen therapy. Interviews with facility staff, including a CNA, LVN, DON, and the Administrator, confirmed that it was standard practice to post oxygen signs to notify others of oxygen use and potential hazards. However, it was revealed that the facility did not have a written policy requiring the posting of such signs. The lack of an oxygen sign was directly observed during the survey, and staff acknowledged the importance of this practice for safety and monitoring purposes.
Failure to Administer and Document Ordered Medication
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for one resident, resulting in missed doses of Megestrol Acetate over a two-day period. The resident, a cognitively intact female with a history of nontraumatic intracerebral hemorrhage, hemiplegia, generalized anxiety disorder, muscle weakness, malnutrition, and anorexia, was admitted with an active order for Megestrol Acetate to treat loss of appetite. Review of the Medication Administration Record showed that the medication was not administered as ordered on three consecutive days, and there was no documented rationale for the missed doses in the resident's progress notes. Interviews with nursing staff and facility leadership revealed that medication aides are responsible for administering most medications, and are required to notify a nurse if a resident refuses medication or if a medication is not administered as ordered. Nurses are then expected to follow up with the resident, document the refusal or missed dose in the progress notes, and notify the physician and DON. However, in this case, there was no documentation of the missed doses or any follow-up actions in the resident's records, indicating a failure to follow established procedures for medication administration and documentation.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the use of bed rails as enablers and the assignment of a CNA who was involved in a self-reported incident. The resident, an elderly female with anxiety and osteoporosis, was admitted to the facility and had an order for enablers to assist with bed mobility. However, the resident's care plan did not include a focus area for the use of bed rails, nor was it coded in the MDS section for restraints and alarms. Additionally, after an incident where the resident injured her wrist on a bed rail during care, the facility did not update the care plan to prevent the involved CNA from being assigned to the resident again. Interviews with the DON, MDS Coordinator, and Administrator revealed that the care plans were not accurately reflecting the resident's needs and risks associated with the use of bed rails. The DON acknowledged the absence of a focus area or intervention for bed rail use in the care plan, and the MDS Coordinator confirmed that the care plan should have addressed the incident involving the CNA. The lack of a comprehensive care plan could lead to residents not receiving necessary care or services tailored to their needs.
Failure to Assess Bed Rail Safety Risks for Resident
Penalty
Summary
The facility failed to assess a resident for the risk of entrapment from a bed rail prior to its installation. This deficiency was identified for one resident who was reviewed for the use of enablers, specifically bed rails. The resident, an elderly female with anxiety and osteoporosis, was admitted to the facility without a Bed Transfer Bar Evaluation Assessment to determine the appropriateness of the bed rails for her needs. Despite having a BIMS score indicating little to no cognitive impairment, the resident was dependent on staff for activities of daily living such as toileting and repositioning in bed. The resident's care plans did not include a focus area for the use of bed rails, and the facility lacked a policy for conducting Bed/Transfer/Bar Assessments. An incident occurred where the resident injured her wrist during incontinence care, reportedly hitting it on the bed rail. The injury was noted by an LVN, who observed swelling and tenderness in the resident's wrist. Although x-rays showed no fractures, the incident highlighted the absence of a proper assessment for the use of bed rails. Interviews with facility staff, including the Administrator and DON, revealed that there was no existing policy for Bed/Transfer/Bar Assessments, and the nursing staff were responsible for ensuring such assessments were completed. The lack of assessment and documentation could potentially place residents at risk of injury from inappropriate or unnecessary enablers.
Privacy Breach During Resident Care
Penalty
Summary
The facility failed to respect the personal privacy of two residents during personal care activities. For Resident #4, the Staff Coordinator did not close the room blinds while weighing the resident, which allowed others to see the care being provided. This oversight was confirmed by LVN C, who observed the situation and intervened by closing the blinds. The Staff Coordinator admitted to not closing the blinds, acknowledging the need to do so for the resident's dignity. Resident #4 had moderate cognitive impairment and was dependent on staff for various activities of daily living. For Resident #8, CNA A left the resident's room door open while retrieving incontinence care items, exposing the resident's brief and private area. CNA A acknowledged the importance of closing the curtain or door to maintain privacy during such care. The resident had a history of dementia and was dependent on staff for bed mobility and transfers. Interviews with the NP and DON confirmed that privacy should be maintained during incontinence care, emphasizing the moral obligation and training provided to staff.
Inaccurate MDS Assessment for Bed Rail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding the use of bed rails, also referred to as enablers. This deficiency was identified for one resident who was admitted to the facility with a history of anxiety and osteoporosis. The resident's admission orders included the use of bed rails to assist with bed mobility and control, yet the MDS did not reflect this use in Section P, which covers restraints and alarms. Additionally, the resident's baseline and comprehensive care plans lacked a focus area for bed rail use, despite the resident's dependence on staff for activities of daily living (ADLs) such as toileting and repositioning in bed. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed a lack of awareness and understanding regarding the coding of bed rails in the MDS. The DON acknowledged the oversight and expressed the need to review the risks associated with not coding the bed rails. The MDS Coordinator confirmed that the resident used bed rails but was not coded for them in the MDS, and was unsure of the risks involved. The facility's MDS policy mandates accurate completion and transmission of MDS assessments, yet this policy was not adhered to in this instance, potentially placing residents at risk of inadequate care.
Failure to Ensure Safe Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent accidents for a resident. The incident involved a staff coordinator who was weighing a resident using a mechanical lift without locking the brakes and without the assistance of a second staff member, as required by the facility's policy. This action was observed by a Licensed Vocational Nurse (LVN) and confirmed during interviews with the staff coordinator and the Director of Nursing (DON). The facility's policy mandates that two staff members are required to operate a mechanical lift to ensure the safety of both the resident and the staff. The resident involved had a history of falls and was diagnosed with conditions such as Diabetes Type 2, right leg pain due to a fall, and ankylosing spondylitis of the thoracic region. The resident was dependent on staff for activities of daily living and required a Hoyer lift with two aides for transfers, as noted in the care plan. The staff coordinator admitted to not applying the brakes on the mechanical lift and acknowledged the risk of injury due to this oversight. The facility's mechanical lifts policy, dated February 2023, emphasizes the need for two staff members during the use of mechanical lifts to ensure safe patient handling and employee safety.
Failure to Provide Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling Foley catheter, leading to a risk of urinary tract infection. The resident, who was admitted with a history of diabetes and a severe ankle fracture, was observed with a catheter bag that was full of dark brownish urine, and the tubing contained a pink, cloudy substance. Despite the resident's ability to recall and make daily decisions, the catheter bag was not emptied in a timely manner, allowing the urine to back up into the tubing. This oversight was noted during an observation and interview with the resident, who reported that the nursing staff drained the catheter bag 3-4 times a day. Interviews with facility staff, including a CNA and the NP, revealed that the CNAs were responsible for checking and draining catheter bags at the end of each shift. The CNA acknowledged that a full catheter bag could cause reverse backflow, potentially leading to infection. The NP emphasized the importance of preventing full or cloudy tubing to avoid bacterial growth and UTIs. The DON confirmed that CNAs should report any issues with the catheter, such as sediment or discoloration, to the nurse and that catheter bags should be emptied when they are half full. The facility's Foley Catheter Policy mandates routine catheter care and notification of the DON/ADON for any issues, which was not adhered to in this instance.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed multiple instances of improper food storage and cleanliness in the kitchen. Food containers had accumulations of dried drippings and residue, and food preparation areas had dust, encrusted grease deposits, and other soiled accumulations. Additionally, food in the refrigerator was found with expired dates, and bananas were stored next to a dirty trash bin. The Dietary Manager was observed entering the kitchen without a beard guard, which was later corrected but not fully compliant as the mustache was not covered. Interviews with the Dietary Aide and the Dietary Manager confirmed the risks associated with these practices, including potential contamination and foodborne illnesses. The Dietary Aide acknowledged that residues on bottles and storing expired vegetables could lead to illness for the residents. The Dietary Manager admitted that using expired flour tortillas could pose a risk of bacteria growth and digestive infections. Furthermore, the kitchen had no tracking system in place to record when cleaning tasks were completed, and the grill, griddle, and deep fryer were found dirty with food residues and grease. The facility's policies and procedures on food storage, use of gloves/hairnets, and general sanitation of the kitchen were reviewed and found to be comprehensive. However, the observations and interviews indicated that these policies were not being followed. The lack of adherence to proper food safety and sanitation practices places residents at risk of foodborne illnesses, as confirmed by the Dietary Aide and the Dietary Manager.
Failure to Implement Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for three residents, which included necessary instructions to provide effective and person-centered care. Resident #35, who had severe osteoporosis and multiple fractures, was not provided with a baseline care plan that included her preference for a vegetarian diet. Despite her dietary needs being documented in her medical records and communicated to the dietary staff, the baseline care plan did not reflect this preference, leading to concerns about her nutritional intake and overall health. The dietary manager and dietitian were aware of her vegetarian diet but did not ensure it was included in the care plan, resulting in the resident relying on family members to supplement her diet. Resident #89, who had Type 2 Diabetes Mellitus with renal complications, did not have her diabetes management included in her baseline care plan. Her medical history indicated the need for monitoring blood sugar levels and insulin administration, but there were no orders or care plans addressing her diabetes. Staff members, including an RN and the MDS Coordinator, were unaware of her diabetes diagnosis, which led to a lack of necessary monitoring and treatment for her condition during her stay at the facility. Resident #192, who required pressure reducing boots as per physician orders, did not have this need included in his baseline care plan. Additionally, neither the resident nor his representative was involved in the care planning process or provided with a copy of the baseline care plan. The DON acknowledged the oversight and the risk it posed to the resident's care. The facility's policy required the development and implementation of a baseline care plan that reflects the resident's goals and needs, but this was not adhered to in these cases.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #11, a female with multiple complex medical conditions including a tracheostomy, did not have her tracheostomy care included in her comprehensive care plan. Despite having orders for tracheostomy care, the MDS Coordinator missed including this critical aspect in the care plan, which could result in staff not identifying and addressing her care needs properly. The DON acknowledged that comprehensive care plans were not completed accurately due to a lack of training and stated that it was the MDS Coordinator's responsibility to complete them accurately. This oversight was confirmed by the MDS Coordinator, who admitted to missing the tracheostomy in the care plan, potentially leading to unaddressed care areas for the resident. Resident #35, who had severe osteoporosis and multiple fractures, had a preference for a vegetarian diet that was not included in her comprehensive care plan. Although her diet order and MAR indicated she was to receive a vegetarian diet, her care plan only mentioned maintaining her nutrition without specifying her dietary preference. The resident expressed concerns about not receiving a balanced diet and had to rely on family members to supplement her meals. The Dietary Manager and Dietitian were aware of her dietary needs, but the MDS Coordinator admitted that the resident's vegetarian preference should have been care planned to ensure the facility followed vegetarian guidelines. The lack of a specific care plan for her dietary preference posed a risk of not meeting her nutritional needs. Resident #89, who had Type 2 Diabetes Mellitus with kidney complications, did not have her diabetes care adequately addressed in her comprehensive care plan. Although her medical history and discharge instructions emphasized the need for monitoring her blood sugar, her care plan only mentioned risks related to skin breakdown and nutrition due to diabetes, without including blood glucose monitoring. The RN who worked with the resident was unaware of her diabetes diagnosis, and the MDS Coordinator admitted to not knowing about the diagnosis, which should have been care planned. The DON confirmed that the diabetes diagnosis should have been included in the care plan to ensure proper monitoring and availability of medications. This oversight could lead to unmonitored diabetic issues for the resident.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to ensure that Resident #35 received appropriate treatment and care for a wound on her left inner knee from 03/30/2024 to 04/09/2024. Despite the resident's medical history of severe osteoporosis, multiple fractures, and systematic lupus erythematosus, which put her at risk for wound healing complications, the facility did not provide the necessary wound care as per professional standards and the comprehensive person-centered care plan. The resident's baseline care plan did not identify any skin conditions at the time of admission, and the wound was first documented on 03/30/2024 but was not treated until 04/09/2024 when a physician's order was initiated for wound care treatment. However, the treatment was inconsistently provided, with several instances noted where wound care was not administered because the resident was asleep. Interviews and observations revealed that the resident was aware of the wound and reported that the facility did not address it until a physical therapist noticed it. The resident stated that the wound care nurse had difficulty locating her to provide treatment. The Director of Nursing (DON) could not explain the delay in wound care and acknowledged the risk of the wound worsening and potential infection due to the delay in treatment. The facility's policy required comprehensive skin evaluations and adherence to treatment orders, which were not followed in this case. The deficiency was identified through record reviews, interviews, and observations, highlighting the facility's failure to provide timely and appropriate wound care for Resident #35. This lapse in care could result in residents not receiving the necessary treatment for wounds, posing a risk to their health and well-being.
Failure to Label Enteral Feeding Formula Bag
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding. Specifically, the facility did not label the enteral feeding formula bag with the resident's name, type of feeding, frequency, time, and date administration started. This deficiency was observed for one resident who was receiving continuous feedings with Jevity 1.2 via a g-tube. The lack of labeling could lead to the resident receiving incorrect feeding formula or an incorrect quantity of formula. The resident involved was [AGE] years old and had been admitted to the facility with diagnoses including diabetes and intractable nausea and vomiting. The resident was to receive nothing by mouth and was on continuous enteral feedings. During an observation, it was noted that the feeding formula bag and water bag hanging beside the resident's bed were not labeled. Interviews with the LVN and DON confirmed that the bags should have been labeled according to the facility's policy, but they were not. The DON was unable to provide documentation or a policy on labeling of enteral feeding bags before the survey exit.
Latest citations in Texas
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
