Clyde W Cosper Texas State Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Bonham, Texas.
- Location
- 1300 Seven Oaks Rd, Bonham, Texas 75418
- CMS Provider Number
- 675873
- Inspections on file
- 29
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Clyde W Cosper Texas State Veterans Home during CMS and state inspections, most recent first.
Dirty Shower Rooms and Improper Trash Removal: The facility failed to keep 2 shower rooms clean and homelike. An observation found A Hall shower stalls with yellowish-brownish grime and pink buildup, and C Hall stalls with black grime on the walls, corners, and grout. A used band-aid was also left in a C Hall stall near body wash. Staff said the stalls were not deep cleaned as scheduled because of staffing shortages, and multiple staff acknowledged the shower rooms were dirty and needed to be scrubbed.
Expired medications were found in multiple medication storage areas and on a medication cart, including a resident’s lorazepam gel and acetaminophen suppositories, additional acetaminophen suppositories in a refrigerator, and famotidine tablets on a medication cart. Staff said nurses, MAs, and unit managers were responsible for checking expiration dates and removing outdated medications, and the facility policy required outdated medications to be immediately removed from stock and disposed of properly.
Medication labeling and storage were not maintained for two residents and two medication carts. An opened UTI-Stat bottle and an opened Pro-Stat bottle were left undated, expired famotidine was found on a cart, and a budesonide package lacked a pharmacy label and resident name. One resident's glipizide, finasteride, gabapentin, and metformin labels did not match current PEG-tube orders, and another resident's Systane eye drops were left on his nightstand instead of being secured in the med cart.
Kitchen food-contact surfaces were not maintained in sanitary condition. Surveyors observed a deep fryer with crumbs around it, a medium skillet with black carbon buildup inside and outside, and a large Teflon-coated skillet with peeling coating on the inside. Dietary staff and the ADM/Dietary Mgr acknowledged the fryer should be cleaned after use and that the damaged skillets needed replacement, but the conditions remained present during repeated observations.
A resident with dementia and severe cognitive loss was not addressed by his preferred name during care. While two CNAs were providing care, one CNA repeatedly called him by his last name even after he loudly stated he wanted to be called by his first name. Interviews showed the CNAs and an LVN were unaware of or disregarded the resident’s stated preference, while the DON and Administrator said residents should be called by their preferred names.
MDS inaccurately coded oxygen use for a resident with COPD. The quarterly MDS did not show oxygen during the look-back period even though the physician order summary and TAR reflected oxygen at 3L via N/C, and the care plan addressed oxygen-related needs. The MDS Coordinator stated she misunderstood the order and TAR and should have coded yes to oxygen use; the DON, Director of MDS, and Administrator all expected the assessment to be coded accurately.
PASARR services were not properly coordinated or documented for one resident with schizophrenia, anxiety, and bipolar disorder. The PASARR care plan called for group therapy, individual therapy, and routine case management, but the chart lacked documentation of those services, and staff said there was no consistent system to track PASARR visits or records. The facility also did not complete a PASARR Level II reassessment for another resident after a new diagnosis of major depressive disorder was added, even though the MDS nurse said a Form 1012 should have been completed.
Care plan not implemented for bedside floor mats: A resident with repeated falls, moderately impaired cognition, and dependence for transfers had an active order and care plan intervention for cushioned floor mats on both sides of the bed when in bed. However, repeated observations found only one mat on the right side, and staff interviews confirmed the resident should have had mats on both sides and that nursing staff were responsible for ensuring they were in place.
A facility failed to ensure that oxygen concentrator filters were cleaned for two residents with COPD and oxygen orders. Surveyors observed one resident’s filter covered in a gray-like substance and another resident’s filter with thick gray, fuzzy material on multiple occasions while both residents were using or ordered oxygen. Staff confirmed the filters were dirty, and the facility policy required oxygen filters to be cleaned daily with soap and water.
Failure to Complete Ordered Lab Monitoring: A resident with a stage 4 pressure ulcer, vitamin D deficiency, diabetes, kidney disease, and dementia did not have ordered Albumin and Pre-Albumin labs completed on schedule, and ordered yearly Vitamin D and lipid panel testing was not documented as obtained. The physician expected labs to be done as ordered, while the LVN, DON, and Administrator each stated labs were supposed to be tracked and completed through the facility’s routine process, but the DON was unaware the resident was missing labs until surveyor intervention.
Incorrect portion sizes were served during lunch when a dietary aide used a #20 scoop instead of the required #16 scoop for a pureed roll and an ADM served only 1/2 cup of chicken cacciatore instead of the ordered 1 cup. Staff said they did not verify the extended menu before serving, and the Dietary Mgr and ADM acknowledged the menu should have been followed.
A resident with Parkinson’s disease, dysphagia, cognitive impairment, and weight loss had a physician order for a health shake with meals as part of a therapeutic diet. During meal service, the shake was not on the tray and no substitute was offered; staff said the dietary aide forgot it and the LVN missed it when checking trays, while the resident reported he sometimes receives the shake and sometimes does not.
Failure to provide ordered PT services after fall screenings. A resident with repeated falls, intact cognition, and wheelchair use had care plan interventions for therapy screening as indicated. After two post-fall therapy screens, PT was recommended, but therapy did not start. Interviews showed the DOR left a message about copay assistance and did not follow back up, while the resident, family, and PT EE all reported no therapy had begun.
A resident on droplet precautions was observed receiving a blood sugar check by an LVN who wore gloves only and did not wear the required gown or mask. In a separate event, a CNA and an RN provided incontinent care to another resident without proper glove changes or hand hygiene, including touching the resident’s pillow and call light with dirty gloves and handling clean items with the same gloves. Both residents had conditions that increased care needs, and staff acknowledged the improper infection control practices.
A resident with Alzheimer’s disease, major depressive disorder, and other comorbidities was receiving three antidepressant medications daily per the MAR, yet the Quarterly MDS assessment was coded to indicate no antidepressant use in Section N0415. The MDS Coordinator, who used the RAI 3.0 User’s Manual and had documentation showing antidepressant use, acknowledged making a data input error. The DON confirmed the resident was on antidepressants and that the MDS should have reflected this, while the Administrator emphasized the importance of accurate MDS coding to report resident needs.
A resident with a history of CVA with hemiplegia, osteoarthritis, and Type II DM, who used a wheelchair for mobility and had intact cognition, was being transported in the facility’s van when the wheelchair tipped over as the van turned a corner, causing a head contusion. Documentation and a written statement from the van driver indicated that the wheelchair had been strapped in, but one of the straps was not placed at the lowest position, contrary to the facility’s transportation policy requiring wheelchair residents to be secured per manufacturer instructions with proper tie-downs. The resident confirmed that the chair tipped during a turn and that he struck his head, while interviews and observations of other drivers and transport aides showed they had received training and were able to correctly secure wheelchairs and residents during transport. The DON reported that nursing staff and charge nurses are responsible for ensuring residents are appropriately seated and prepared for van transport before being picked up by transport staff.
Two residents with severe cognitive impairment and orders for nectar-thickened liquids were provided with thin liquids instead, both during meal service and at their bedsides. Staff failed to check tray contents and bedside liquids for correct consistency, resulting in the residents consuming inappropriate fluids despite clear dietary orders and care plans.
A resident with a broken ankle and a soft splint developed four unstageable deep tissue injuries due to the facility's failure to obtain clarification orders for splint care and perform necessary skin assessments. Despite the resident's high risk for pressure ulcers, the facility did not document or follow up on care instructions, leading to worsening conditions and potential osteomyelitis.
A resident with dementia and a history of exit-seeking behavior was found outside the facility with her wheelchair tipped over, indicating a failure in supervision and intervention. Despite known risks, the facility did not effectively monitor or prevent the resident from leaving, leading to an Immediate Jeopardy situation.
The facility failed to provide trauma-informed care for four residents, as trauma screenings were not completed upon admission, and care plans did not identify potential triggers despite residents' PTSD diagnoses. This oversight increased the risk of re-traumatization, as staff were unaware of residents' triggers. Interviews revealed that staff were not informed about the residents' trauma histories, emphasizing the need for proper documentation and communication.
The facility failed to ensure proper labeling and storage of drugs and biologicals, affecting a resident, a medication cart, and a medication room. An LVN left a medication cart unlocked, and lock boxes with controlled substances were not affixed in the Secure Unit Medication Room. A resident had medications at bedside without assessment for self-administration. Staff interviews revealed expectations for medication security were not met, and the facility's policy lacked guidance on these issues.
The facility failed to obtain timely laboratory services for three residents, including annual T4 Free and PSA tests for a resident with hypothyroidism and vitamin deficiency, and Free T4 tests for two residents with hypothyroidism. The DON was unaware of the missing labs until the state surveyor's intervention, highlighting a need for improved lab monitoring processes.
The facility failed to maintain an effective infection control program, as staff did not adhere to PPE and hand hygiene protocols. A resident on contact isolation was visited by staff without proper PPE, and two LVNs did not perform hand hygiene between glove changes during care procedures. These lapses could lead to infection spread among residents.
A resident with cognitive impairment and incontinence requested incontinent care before lunch, but a CNA failed to comply, citing cross-contamination concerns. The resident had asked twice, and the CNA stated she would change him after lunch, despite the facility's policy on respect and dignity.
A resident with vascular dementia and bipolar disorder was inappropriately restrained by a CNA during a bed bath, despite refusing care. The CNA admitted to holding the resident's wrist against the bed to prevent combative behavior, contrary to facility policy. Interviews revealed that proper protocols for handling care refusal were not followed, leading to a violation of the resident's rights.
The facility failed to ensure accurate PASRR screenings for two residents with mental health disorders. One resident with PTSD and dementia was readmitted without a correct PASRR Level 1 Screening, while another with bipolar disorder had an outdated negative screening. Errors were acknowledged by the MDS Coordinator, who admitted confusion about the PASRR process and had not conducted a full audit of resident charts.
A facility failed to include a resident's PTSD diagnosis and triggers in the baseline care plan upon admission. The resident, a former Marine, had specific triggers related to his military experience, which were not documented due to the incomplete trauma assessment. Staff interviews confirmed the oversight, highlighting the risk of staff unknowingly triggering the resident.
The facility failed to update care plans for two residents, one requiring contact isolation due to ESBL and another refusing incontinent care and bathing. Despite staff awareness and existing medical orders, these issues were not documented in the care plans, contrary to facility policy.
A resident requiring oxygen therapy did not receive proper respiratory care as the facility failed to change the oxygen tubing weekly as per policy. The tubing was observed to be outdated, and staff interviews revealed lapses in protocol adherence, placing the resident at risk for infection.
The facility failed to adhere to medication administration protocols for two residents, leading to the administration of anti-hypertensive medication without ensuring blood pressure met prescribed parameters. Staff interviews revealed a lack of adherence to protocols, placing residents at risk of harm.
Dirty Shower Rooms and Improper Trash Removal
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in 2 shower rooms reviewed for homelike environment. In the A Hall shower room, an observation with LVN D found 3 shower stalls with yellowish-brownish grime from the middle down to the lower part of the tile on the shower walls, and one stall also had pink grime buildup. LVN D stated the stalls appeared clean and said CNAs sprayed down the shower stalls after resident showers, while housekeepers performed a deeper clean. In the C Hall shower room, an observation with RN L found 2 stalls with black grime buildup on the lower parts of the shower walls, corners, and scattered on the grout of the tile floor. One stall also had a slightly folded over band-aid with illegible writing lying next to bottles of body wash in a built-in cavity/shelf on the shower wall. RN L stated housekeepers cleaned the shower stalls once a day, CNAs should remove trash and not leave used band-aids in the shower stalls, and it appeared like there was mold on the shower stalls. RN L also stated CNA M and CNA W provided resident showers that day. During interviews, CNA M and CNA W said they did not know who left the band-aid in the C Hall shower stall and stated trash should not be left in shower stalls after a resident shower. Housekeeper H, Housekeeper O, and the Housekeeping Supervisor all stated the A Hall and C Hall shower stalls were dirty and needed to be scrubbed; they also said the showers were not deep cleaned on the prior Sunday because there were not enough housekeepers. Housekeeper P said the last time he scrubbed the shower stalls was 2-3 weeks ago. The Administrator stated he expected the shower rooms to remain clean and hygienic and said he and housekeeping staff were responsible for ensuring the shower rooms were clean. The facility policy titled Resident Rights stated the resident has a right to a safe, clean, comfortable, and homelike environment.
Expired Medications Found in Storage Areas and Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate dispensing and administration of drugs and biologicals and that drug records were in order with controlled drugs accounted for and periodically reconciled. During survey observations and record review, expired medications were found in multiple medication storage areas and on a medication cart, including Resident #118’s lorazepam gel and acetaminophen 650 mg suppositories in the Memory Care Medication Storage Room, acetaminophen 650 mg suppositories in the A Hall Medication Storage Room refrigerator, and famotidine 10 mg tablets on the 600 Hall Medication Aide Medication Cart. Resident #118 was an elderly female admitted with diagnoses including dementia and anxiety disorder. Her MDS assessment indicated a BIMS score of 3, showing severely impaired cognition, and she required assistance with eating, toileting, bathing, and personal hygiene. Her order summary showed Ativan gel 0.5 mg/ml to be applied topically every 6 hours as needed. During an observation with an RN, the Memory Care Medication Storage Room refrigerator contained a box of acetaminophen 650 mg suppositories with 11 remaining and an expiration date of 03/2026, along with 1 syringe of lorazepam gel 0.5 mg/1 ml with an expiration date of 04/14/2026, both belonging to Resident #118. Additional observations found a box of acetaminophen 650 mg suppositories with 7 remaining and an expiration date of 01/2026 in the A Hall Medication Storage Room refrigerator, and 30 tablets of famotidine 10 mg with an expiration date of 11/2025 on the 600 Hall Medication Aide Medication Cart. Staff members stated that nurses, medication aides, and unit managers were responsible for checking medications for expiration dates, and several staff acknowledged the expired medications should have been removed and discarded. The facility policy stated that outdated medications are to be immediately removed from stock and disposed of according to medication disposal procedures.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to accepted standards for two residents and two medication carts. During observation of the 600 Hall MA medication cart, an opened bottle of UTI-Stat and an opened bottle of Pro-Stat were found without dates showing when they were opened, and 30 tablets of famotidine 10 mg were also present with an expiration date of 11/2025. The MA stated the items should have been dated when opened and that expired medications could be ineffective. Resident #161 had physician orders for glipizide 5 mg via PEG tube twice daily, finasteride 5 mg via PEG tube daily, gabapentin 100 mg via PEG tube daily, and metformin 1000 mg via PEG tube twice daily. During medication administration, LVN A halved a glipizide 10 mg tablet because the label still reflected the prior order for 10 mg by mouth twice daily before meals. The labels for finasteride, gabapentin, and metformin also continued to show administration by mouth rather than via PEG tube. LVN A stated a change-of-direction sticker should have been placed on the medications when the route and dose changed, and the ADON and DON stated the labels should have reflected the current orders. On the 200 Hall nurse medication cart, a package of budesonide 0.5 mg/2 ml with 5 ampules was found without a pharmacy label or resident name. LVN F stated he did not know which resident the medication belonged to and that medications should remain in the original labeled packaging from the pharmacy. In addition, Resident #20, who had dementia and acute conjunctivitis of the left eye, had a bottle of Systane Ultra eye drops left on his nightstand during multiple observations. Staff and the resident's family member stated the eye drops should have been stored in the nurse's cart, and staff noted the resident was not competent to self-administer his medications.
Kitchen Food-Contact Surfaces Not Kept Clean and in Good Repair
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During observations of the kitchen, the deep fryer had crumbs around it, one medium-sized skillet had black carbon buildup on the inside and outside, and one large-sized skillet with Teflon coating had peeling on the inside. These conditions were observed on more than one occasion during the survey, and the report stated that the fryer, skillets, and other food-contact surfaces were not maintained in the condition expected by the facility's cleaning and sanitation policy and the FDA Food Code. During interviews, dietary staff and administration acknowledged the conditions. The Assistant Dietary Manager stated the fryer should not have crumbs and that the medium skillet with carbon buildup should have been discarded long ago; she also said the Dietary Manager was responsible for ensuring the skillets were in good condition and replaced. The Dietary Manager said the fryer should be cleaned after each meal by the cook who used it, but he had not checked it the prior day, and he was aware the medium and large skillets needed replacement but had missed it. The cook said the fryer was scraped and baskets washed after use, but sometimes staff did not get around to cleaning it or forgot. The Administrator said he had not noticed the fryer crumbs or the damaged skillets during his walk-throughs and expected the kitchen to remain clean and hygienic.
Resident Called by Last Name Instead of Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not using his preferred name during care. Resident #76 was a male resident admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood and vascular dementia, and his significant change MDS indicated a BIMS score of 03 with severe cognitive loss. His care plan, dated 11/25/25, identified that he preferred to be called by his first name, with interventions to respect his wishes. During an observation and interview on 04/28/26 at 8:55 AM, CNA Z and CNA AA were providing care while calling Resident #76 by his last name. The resident loudly told them he did not want to be called by his last name and stated that his name was [name] and that was what he wanted to be called. CNA Z called him by his last name again, and the resident immediately corrected her. During interviews, CNA AA said she always called him by his last name and believed that was his name, while CNA Z said she had always called him by his last name and was not aware he preferred his first name. LVN W stated she typically called all residents by their last names out of respect and was not aware of the preference, and the DON and Administrator stated residents should be called by their preferred names.
MDS inaccurately coded oxygen use
Penalty
Summary
Resident #28’s quarterly MDS, dated 04/08/26, did not accurately reflect that he was receiving oxygen during the 7-day look-back period. The resident was a [AGE] year-old male admitted with COPD, and his physician order summary showed an active order for oxygen at 3L via nasal cannula as needed for shortness of breath and to maintain oxygen saturation above 90 percent every shift, with a start date of 04/16/26. The TAR also reflected that he wore oxygen at 3L via nasal cannula on 04/02/26 through 04/08/26, yet the MDS was coded as not receiving oxygen. Record review also showed an active order to check, clean, and/or replace the oxygen filter every week on Wednesday night shift, and the care plan reflected that the resident may receive oxygen related to acute respiratory failure with hypoxia, hypercapnia, and pneumonia. During interview, the MDS Coordinator stated she misunderstood the physician order and TAR and should have coded yes to oxygen use. The Director of MDS, DON, and Administrator each stated they expected the MDS to be coded accurately and identified the MDS Coordinator as responsible for the incorrect coding.
PASARR services and reassessment were not coordinated or documented
Penalty
Summary
The facility failed to coordinate and document PASARR-related services for a resident with serious mental illness. Resident #102 was admitted with schizophrenia, anxiety, and bipolar disorder, had a BIMS score of 15, and his care plan identified a need for specialized services due to mental illness. The PASARR Comprehensive Service Plan meeting documented recommendations for group therapy, individual therapy, and routine case management, but the resident’s electronic record did not contain documentation of those services through the date reviewed. During interviews, the PASARR Case Manager stated she visited the facility monthly to obtain a report from the resident and follow up with nurses, but she did not leave documentation of the visits. The MDS Coordinator stated she was responsible for ensuring PASARR Case Manager visits were conducted, was not aware when the skill trainer visited, and did not coordinate with them after visits. The DON stated he and the corporate nurse would try to obtain evidence of services provided, and the Administrator stated he did not know what services the resident was receiving until surveyor intervention and that there was no system in place to monitor MDS Coordinator oversight of needs. The facility also failed to complete a PASARR Level II assessment for another resident after a new diagnosis of Major Depressive Disorder was added after admission. Resident #86 had diagnoses including hemiplegia/hemiparesis following cerebral infarction, anxiety disorder, and insomnia, and later had Major Depressive Disorder documented on the face sheet. The annual MDS indicated no serious mental illness, and the electronic record did not show a Form 1012 had been completed for the new diagnosis. The MDS Nurse stated she should have completed a Form 1012 for the diagnosis and that she received psychiatric notes by email.
Care Plan Not Implemented for Bedside Floor Mats
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #28 that included measurable objectives and timeframes to meet his medical, nursing, and mental needs. Resident #28 was a [AGE]-year-old male admitted with diagnoses including repeated falls. His quarterly MDS dated 04/08/26 reflected that he made himself understood and understood others, had a BIMS score of 8 indicating moderately impaired cognition, was dependent with chair/bed-to-chair transfer, and had no falls since admission/entry, reentry, or the prior assessment. Record review showed an active order dated 12/27/24 to ensure a cushioned floor mat on the floor on each side of the bed when the resident was in bed, and the care plan also listed cushioned floor mats on both sides of the bed as an intervention. However, during observations on 04/26/26, 04/27/26, and 04/28/26, the resident was lying in bed with a cushioned floor mat only on the right side of the bed. During interview, the resident stated he did not know if he should have a cushioned floor mat on his left side. Staff interviews confirmed that nursing staff were responsible for ensuring the mats were in place and that the resident should have had a floor mat on each side of the bed.
Dirty Oxygen Concentrator Filters Not Maintained
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who had oxygen orders and respiratory diagnoses. Resident #56 had COPD and anxiety, was cognitively intact, and had a care plan and physician order to check, clean, and/or replace the oxygen concentrator filter every Wednesday night shift. During observation, the resident was using oxygen at 2 liters per minute and the concentrator filter was covered in a gray-like substance. The dirty filter was observed again on a later date, and an LVN verified that it was dirty and stated nurses were supposed to look at the oxygen equipment daily. Resident #28 had COPD and a history that included acute respiratory failure with hypoxia, hypercapnia, and pneumonia. The resident had an active order for oxygen at 3 liters via nasal cannula as needed for shortness of breath and another order to check, clean, and/or replace the oxygen filter every Wednesday night shift. The resident’s oxygen concentrator filter was observed on multiple occasions to have a thick, gray, fuzzy material on it while the resident was in bed. An LVN observed the filter and stated it was dirty and that cleaning filters was important to prevent respiratory infection. Staff interviews showed that the Wednesday night nurse was responsible for cleaning or changing the oxygen filters, while charge nurses, unit managers, the DON, and ambassador rounds were also expected to monitor the equipment. However, the filter for each resident remained visibly dirty during the survey observations. The facility’s oxygen administration policy stated that filters were to be cleaned daily with soap and water.
Failure to Complete Ordered Lab Monitoring
Penalty
Summary
The facility failed to provide or obtain laboratory services to meet the needs of Resident #12. The record showed orders for Albumin to be drawn monthly and Pre-Albumin to be drawn bi-weekly to assist the registered dietitian with nutritional assessment and pressure wound care, but the resident's electronic medical record did not show the ordered labs were completed as scheduled. The record also showed orders for Vitamin D and Lipid panel testing yearly, and the electronic medical record did not indicate that either test had been obtained since the orders were placed. Resident #12 was an [AGE]-year-old male with diagnoses including a stage 4 pressure ulcer, vitamin D deficiency, diabetes, kidney disease, and dementia. The comprehensive care plan identified that he was at risk for complications related to vitamin D deficiency and impaired thought process related to liver cirrhosis, with interventions that included labs as ordered, medication as ordered, and observation for complications. A later care plan revision again identified him as at risk for complications related to wounds and included labs as ordered. During interviews, the physician stated he expected labs to be done as ordered. The LVN said nurses were responsible for completing lab slips, placing new orders on the 24-hour report, and checking the lab book daily for routine labs, and she was not aware of any missed labs for Resident #12. The DON and Administrator both stated they expected labs to be drawn as ordered and said nurse management was responsible for ensuring completion; the DON also stated he was unaware the resident was missing labs until the surveyor intervention. The facility policy stated laboratory services would be performed as ordered by the physician and completed on the date specified or the next scheduled lab day if no specific date was identified.
Incorrect Portion Sizes Served at Lunch
Penalty
Summary
The facility failed to ensure menus were followed for the lunch meal and that the portions served matched the extended menu. During observation and interview in the kitchen on 04/27/2026 at 11:22 AM, [NAME] B served the lunch meal for residents who ate in the halls and used a #20 scoop to serve the pureed bread, even though the extended menu required a #16 scoop for the pureed wheat dinner roll. During observation and interview in the main dining room on 04/27/2026 at 11:43 AM, the Assistant Dietary Manager said she was using only 1/2 scoops to serve the lunch meal and served 1/2 cup of chicken cacciatore to residents in the main dining room, while the extended menu required 1 cup of Chicken Cacciatore Pasta. During interview on 04/28/2026, [NAME] B said she normally checked the extended menu before serving but did not do so on 04/27/2026 because the same scoop sizes are usually used for each meal. She acknowledged the #20 scoop was smaller than the required #16 scoop and said using the smaller scoop could mean residents were not getting enough food. The Assistant Dietary Manager said she also did not check the extended menu on 04/27/2026 because she was not supposed to serve the lunch meal, and she stated that serving less than required could leave residents underfed and lead to malnutrition. The Dietary Manager and Administrator both stated they expected staff to use the correct scoop sizes and that not doing so could lead to residents receiving less nutrition and weight loss.
Therapeutic Diet Supplement Not Provided as Ordered
Penalty
Summary
The facility failed to ensure a therapeutic diet order was carried out for one resident who had Parkinson’s disease, dysphagia, moderate cognitive impairment, dependence for all eating, and documented weight loss. The resident’s record showed a physician order for a health shake with meals as part of a therapeutic diet plan for nutritional support, along with a mechanically altered diet and nectar consistency. The care plan addressed actual weight loss related to diet change and decreased oral intake, with an intervention for diet as ordered. During meal service observation, the resident did not receive the ordered health shake with the lunch tray, and no substitute supplement was offered or provided at that time even though the meal ticket listed the shake. The resident stated he had not received the shake and said he sometimes gets it and sometimes does not. Staff interviews showed the CNA was unaware the shake had not been delivered, the dietary aide said she forgot to put it on the tray, the LVN stated she must have missed it when checking the tray, and the dietary manager said the order was supposed to be followed from the meal tickets. The DON and Administrator both stated the resident was expected to receive the health shake with meals.
Failure to Provide Ordered PT Services After Fall Screenings
Penalty
Summary
The facility failed to provide specialized rehabilitative services for Resident #67, a male resident with a diagnosis of repeated falls. His significant change of status MDS, dated 02/27/26, reflected that he made himself understood and understood others, had a BIMS score of 13, used a wheelchair, and was independent with self-care abilities and mobility. His comprehensive care plan identified him as at risk for injury related to falls and at risk for impaired mobility related to bone density and structure, with interventions that included therapy screening as indicated. Record review showed Resident #67 had a therapy post-fall screen after a fall on 03/10/26, and PT was recommended. A second therapy post-fall screen after another fall on 03/20/26 also recommended PT. The order summary report reflected an active physician order for PT/OT/ST screen as needed with a start date of 01/30/26. During interview, Resident #67 stated therapy had not started. The DOR stated she called and left a message regarding copay assistance, but did not follow back up, and stated she was not informed by nursing staff that Resident #67 had declined after the later fall. Additional interviews reflected that the family member had asked about therapy when Resident #67 was first admitted and later stated she would pay the copay, but she did not hear anything back. The Director of admission stated she had discussed therapy with the PT EE, while the PT EE stated he was waiting on approval from the DOR to start services. The DON and Administrator stated they expected therapy services to be available as requested and that follow-up should occur to confirm family approval. The facility policy stated therapy services would be available to assist residents in maintaining maximum independence, that residents would be screened upon admission and as needed, and that residents and/or representatives would be involved in the therapy plan.
Infection Control Failures During Droplet Precautions and Incontinent Care
Penalty
Summary
The facility failed to maintain infection prevention and control practices for a resident on droplet precautions. Resident #73 was a male with diagnoses including myelodysplastic syndromes, pancytopenia, and iron deficiency anemia. His physician order and care plan directed staff to follow droplet precautions related to a low white blood count. During an observation, the resident had a droplet sign on his door and a cart outside the room with gloves, gowns, and masks, and he stated staff had been wearing a gown and mask while in his room. During a later observation, LVN E entered Resident #73’s room and performed a blood sugar check while wearing gloves only. She did not have a gown or mask on. When interviewed, LVN E stated she did not know whether she was supposed to wear anything in the room, then checked the door and acknowledged she was supposed to wear a gown, gloves, and a mask. She stated she had not noticed the sign on the door and said not wearing the correct PPE could cause the resident to be transmitted something that could worsen his condition. The DON and Administrator stated they expected staff to wear PPE in the resident’s room and identified unit managers, the ADON, the DON, and the Administrator as responsible for ensuring compliance. The facility also failed to ensure proper glove changes and hand hygiene during incontinent care for Resident #86. Resident #86 was a male with hemiplegia and hemiparesis following cerebral infarction and irritant contact dermatitis related to incontinence. He was dependent for personal hygiene, dressing, bathing, and toileting hygiene, and his care plan identified him as at risk for skin breakdown related to fragile skin, bowel and bladder incontinence, and impaired mobility. During observation, CNA CC and Nurse DD provided incontinent care while wearing gloves, but they did not change gloves when moving between dirty and clean tasks, and Nurse DD donned gloves without performing hand hygiene. CNA CC touched the resident’s pillow and call light cord with dirty gloves and used the same gloves while cleaning, handling the clean brief, and replacing the dirty brief. Both staff members acknowledged the improper technique during interview, and the DON and Administrator stated proper hand hygiene and protocol were expected during resident care.
Inaccurate MDS Coding of Antidepressant Use
Penalty
Summary
The facility failed to ensure that a resident’s Quarterly MDS assessment accurately reflected the use of antidepressant medications. The resident, admitted with diagnoses including Alzheimer’s disease, anxiety, delusional disorder, major depressive disorder, hypertension, hyperlipidemia, and osteoarthritis, was receiving multiple antidepressants according to the medication administration record. The MAR for the look-back period showed daily administration of Mirtazapine 15 mg at bedtime for sadness related to depressive disorders, Trazodone 50 mg (1.5 tablets) at bedtime for sleeplessness related to depression, and Zoloft 100 mg once daily for sadness related to depressive disorders, all with start dates in the prior year. Despite this, the Quarterly MDS assessment dated 02/25/2026 was coded in Section N0415 as the resident not receiving an antidepressant. The MDS Coordinator, who completed the assessment, acknowledged during interview that the resident did receive three antidepressant medications and stated that the incorrect coding was due to an error in data input, despite having documentation indicating antidepressant use and using the RAI 3.0 User’s Manual as her tool. The DON confirmed that the resident received antidepressant medications and should have been coded as such on the MDS, and stated that the MDS Coordinator is responsible for ensuring the accuracy of MDS assessments. The Administrator also stated that MDS accuracy is important to ensure residents’ needs are accurately reported.
Wheelchair Not Properly Secured During Van Transport Resulting in Resident Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safe transport for a resident using a wheelchair in the facility’s transport van, resulting in an accident. An [AGE]-year-old male resident with a history of cerebral infarction with hemiplegia, osteoarthritis, Type II diabetes, major depressive disorder, and overactive bladder, who used a wheelchair for mobility but had intact cognition and independence in most ADLs, was being transported back to the facility from an appointment. According to the facility’s self-report and EMR documentation, as the van turned a corner, the resident’s wheelchair tipped over, causing him to hit the back of his head and sustain a contusion. Record review showed that the van driver involved in the incident stated in a written statement that she had secured the resident’s wheelchair with straps but acknowledged that one of the straps was not at the lowest position. The driver had previously completed driver training and a safety program. The RN Supervisor’s written statement documented that she was notified of the incident by the driver, went to the van’s location, assessed the resident, and then returned him to the facility before the physician was notified and recommended hospital evaluation. The resident was transported to the hospital via ambulance and returned the same day with a diagnosis of head contusion and mild headache, with no new orders. During interviews, the resident confirmed that his wheelchair tipped over when the van turned a corner and that he hit his head on a bar, but he denied that the van was traveling too fast. Additional interviews with current van drivers and transport aides indicated that they had received training and hands-on instruction in wheelchair restraint and passenger securement, and observations of them securing a proxy resident in the van showed proper use of wheelchair tie-downs and seat belt restraints. The DON stated that nursing staff are responsible for ensuring residents are seated in appropriately sized wheelchairs with footrests before transport, and that charge nurses and unit managers must verify residents are adequately prepared for van transport. The facility’s transportation policy required wheelchair residents to be secured per manufacturer instructions using proper tie-downs, which was not fully adhered to in this incident as one strap was not positioned correctly, leading to the unsafe transport condition.
Failure to Provide Prescribed Liquid Consistency for Residents with Dysphagia
Penalty
Summary
The facility failed to provide liquids consistent with the prescribed needs of two residents who required nectar-thickened liquids due to dysphagia. For one resident with Parkinson's disease and severe cognitive impairment, staff did not ensure that the lunch tray contained nectar-thick liquids as ordered. Instead, the resident was given thin liquids, which he drank. The CNA did not initially notice the inconsistency, assuming the nurse had checked the tray, and only corrected the error after confirming the resident's dietary needs. The nurse responsible for checking trays admitted to misreading the diet card and placing thin liquids on the tray, acknowledging the resident was at risk for aspiration as a result. On a subsequent day, the same resident was found with a bottle of thin liquid water at his bedside, which he had been drinking. Neither the resident nor the staff could identify how the water was provided, and the CNA removed it after being alerted. The nurse assigned to the resident stated she had not seen the water bottle earlier and emphasized that all staff were responsible for ensuring the correct liquid consistency was provided. A second resident, also with severe cognitive impairment and on a nectar-thickened liquid order, was observed with thin liquids in a metal cup at his bedside. The resident reported drinking from the cup with his medications. The CNA, after being questioned, checked the cup and removed the thin liquids, stating she had not previously checked the contents. The speech therapist confirmed both residents were on nectar-thick liquids, and the DON and Administrator stated that staff were expected to follow prescribed diets and ensure correct liquid consistency, as outlined in facility policy.
Failure to Prevent Pressure Ulcers in Resident with Ankle Fracture
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for a resident who had broken his right ankle and had a soft splint applied. The facility did not obtain a clarification order from the doctor regarding the care of the splint, leading to the development of four unstageable deep tissue injuries on the resident's right foot and possible osteomyelitis. The resident had a history of dementia and diabetes mellitus and was admitted with no pressure ulcers, but developed stage 3 and stage 4 pressure ulcers after admission. The resident's comprehensive care plan included interventions for impaired mobility and risk of complications related to a fracture, but there were no specific orders for the care of the soft splint. The facility's records showed a lack of documentation and assessment of the splint and the resident's skin condition, despite the resident's high risk for pressure ulcer development as indicated by a Braden Scale score of 15. The facility staff failed to perform neurovascular assessments and did not follow up with the orthopedic doctor for care instructions, resulting in the resident's condition worsening. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's care needs and the importance of assessing the splint and skin condition. The orthopedic doctor had instructed that the splint could be removed for showers, therapy, and assessments, but this information was not effectively communicated or documented by the facility staff. The failure to implement appropriate preventive measures and clarify physician orders contributed to the development of pressure injuries and potential infection in the resident.
Removal Plan
- PT and Charge Nurse removed the soft cast and observed skin impairments. The Treatment Nurse was notified, the areas were evaluated, and the physician was notified. New orders for wound care were initiated. The soft cast remained off and a CAM boot was applied that could be removed for showers allowing skin checks. Care plans were initiated for the skin impairments.
- 100% of all available direct care staff will be trained by the DON or designee and all other direct care staff will be trained before their next scheduled shift on skin check procedures for residents with a splint or cast and wound care prevention. A post-test will be completed at the end of training to ensure effectiveness of training.
- 100% of all available licensed nurses will be trained by the DON/Designee on following physician's orders. All others will be trained before their next scheduled shift.
- The Wound Nurse received 1:1 education on caring for a resident with a cast/splint, following physician's orders and wound care prevention per the Regional Nurse Consultant.
- Skin audits were completed on all residents by the DON/Designees. No new pressure injuries were identified during the audit.
- Care plans were audited for all residents with pressure ulcers and/or risk for pressure ulcers to ensure interventions were accurate and in place by the DON/Designee.
- The DON/Designee reviewed current resident care needs for any resident with a device that is not/cannot be removed. No residents currently reside in the facility with devices that cannot be removed.
- 100% audit of all residents was completed to ensure weekly skin checks are ordered. No issues identified.
- Pressure Ulcer QA tool will be completed weekly X 4 weeks, the monthly X 2 months, and then quarterly. The results will be presented to the QAPI committee, and any areas of deficiency will be immediately addressed through education.
- Wound Care Prevention policy was reviewed, and no updates were indicated by Director of Clinical Operations. This policy was included in the above noted training.
- Medical Director was notified of IJ.
- Facility QAPI meeting will be held to discuss POR.
- This Plan of Removal will be completed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident who was reviewed for supervision. The resident, who had a history of dementia and was wheelchair-bound, was found outside the facility sitting on the curb with her wheelchair tipped over. This incident occurred after previous exit-seeking attempts by the resident, which were not adequately addressed by the facility. The resident had a history of exit-seeking behavior, as noted in her care plan and elopement evaluations. Despite this, the facility did not implement effective interventions to prevent her from leaving the facility unattended. The resident's wander guard was not properly monitored, and she was able to remove it and leave the facility without staff knowledge. Interviews with staff revealed that the resident had been attempting to leave the facility multiple times, and staff were aware of her exit-seeking behavior but were unable to prevent her from leaving. The facility's failure to adequately supervise the resident and implement effective interventions to prevent her from leaving the facility resulted in an Immediate Jeopardy situation. The resident's care plan and elopement evaluations indicated a risk for elopement, but the facility did not take appropriate actions to mitigate this risk. The lack of supervision and failure to address the resident's exit-seeking behavior placed her at risk of harm.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care. This deficiency was identified for four residents who were reviewed for trauma-informed care. The facility did not complete trauma screenings upon admission for two residents, and the care plans for two other residents did not identify possible triggers despite their history of trauma. These failures could increase the risk of severe psychological distress due to re-traumatization. Resident #402, a male with a history of PTSD, did not have a trauma screening completed upon admission. His military service tool indicated triggers from his military experience, such as loud noises and closed doors, but these were not documented in his baseline care plan. The trauma-informed care assessment was only completed after state surveyor intervention, revealing a positive PTSD screen. Social Worker C acknowledged the failure to complete the trauma assessment upon admission, which placed the resident at risk of being triggered unknowingly by staff or visitors. Resident #401 also did not have a trauma screening completed upon admission. Although his trauma-informed care assessment later indicated no PTSD or triggers, the Director of Nursing and the Administrator both stated that the failure to complete the assessment upon admission placed residents at risk. Additionally, Residents #22 and #45 had comprehensive care plans that did not address their history of trauma or potential triggers, despite having PTSD diagnoses. Interviews with staff revealed a lack of awareness of these residents' triggers, which were not documented in their care plans, highlighting the importance of identifying triggers to prevent re-traumatization.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, affecting one resident, a medication cart, and a medication storage room. An unlocked nurse medication cart was observed on the 600 hall, and the responsible LVN admitted to not locking it when stepping away, acknowledging the importance of securing the cart to prevent unauthorized access. Additionally, in the Secure Unit Medication Room, lock boxes containing controlled substances like Ativan, morphine, and hydromorphone were not permanently affixed, raising concerns about potential removal and unauthorized access. Resident #103, a male with chronic ischemic heart disease, was found to have medications at his bedside without proper assessment for self-administration. The resident had a BIMS score indicating intact cognition but had not been evaluated for self-administration of medications. The resident possessed over-the-counter medications, including Cold & Flu cough syrup and Aleve liquid gels, which were not secured, and there was no physician order for self-administration. Staff interviews revealed that the resident had not been assessed for competence in self-administration, and the facility's policy did not address bedside storage of medications. Interviews with facility staff, including the DON and Administrator, highlighted expectations for medication security, such as locking medication carts and affixing lock boxes for controlled substances. However, there was a lack of adherence to these expectations, as evidenced by the unsecured medication cart and non-affixed lock boxes. The facility's policy on medication delivery and receipt did not address the specific issues of locking medication carts or bedside storage, contributing to the deficiencies observed.
Failure to Obtain Timely Laboratory Services for Residents
Penalty
Summary
The facility failed to ensure that laboratory services were obtained to meet the needs of three residents. Resident #49 did not have his T4 Free and PSA lab tests drawn yearly as required. Additionally, his Vitamin D test was not conducted every six months as ordered. These tests are crucial for monitoring his conditions, including hypothyroidism and vitamin deficiency diseases. The records indicated that the last T4 Free test was conducted in February 2024, but there was no record of a Vitamin D or PSA test for the year 2024. Resident #22, who has a diagnosis of hypothyroidism, did not have his Free T4 test drawn every six months as ordered. The last recorded test was in December 2023, and there were no negative outcomes reported from the missed labs. His care plan included interventions such as obtaining labs as ordered and observing for complications related to hypothyroidism. Resident #103, also diagnosed with hypothyroidism, did not have his Free T4 test drawn yearly as ordered. The last test was conducted in January 2023, and like Resident #22, there were no negative outcomes reported from the missed labs. The Director of Nursing (DON) was unaware of the missing labs until the state surveyor's intervention and acknowledged that the facility's routine lab monitoring process might not be effective, indicating a need for review and improvement.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several incidents involving staff not adhering to proper infection control protocols. In one instance, a medication aide entered the room of a resident on contact isolation without wearing the required personal protective equipment (PPE), such as gloves and a gown. The aide was unaware of the facility's policy on contact isolation, despite a sign being posted on the resident's door. Additionally, a housekeeper was observed cleaning the same resident's room without wearing a gown, citing a misunderstanding of the signage requirements. Another deficiency was observed when a licensed vocational nurse (LVN) failed to perform hand hygiene between glove changes while providing wound care to a resident. The LVN also placed a tablet on the resident's dresser without disinfecting it afterward, which could potentially lead to contamination. The LVN acknowledged the oversight and attributed it to nervousness during the observation by a state surveyor. The facility's infection control preventionist and director of nursing (DON) both emphasized the importance of adhering to hand hygiene protocols to prevent the spread of infection. A similar issue was noted with another LVN who did not perform hand hygiene between glove changes while providing catheter care to a resident. The LVN admitted to forgetting the procedure due to nervousness and recognized the potential risk of spreading infection to the resident, who had an indwelling catheter. The DON and other staff members reiterated the necessity of following proper hand hygiene practices to minimize the risk of infection transmission within the facility.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as required by resident rights, during an incident involving a Certified Nursing Assistant (CNA). The resident, who has a history of bipolar disorder, anxiety disorder, traumatic brain injury, and pain, and is always incontinent of bowel and bladder, requested incontinent care before eating lunch. Despite the resident's request, the CNA did not comply, stating that she had changed the resident five minutes prior and would do so after lunch. This interaction was observed by surveyors, and the resident expressed that he had asked for assistance twice already. The CNA justified her inaction by citing concerns about cross-contamination, as meal trays were being distributed in the hallway. However, it was noted that the trays were not present when the resident initially made the request. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, which was not upheld in this instance. The failure to provide timely care could impact the resident's quality of life, dignity, and self-worth.
Inappropriate Use of Physical Restraints on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were imposed for convenience rather than medical necessity. This deficiency was identified during an incident involving a male resident with vascular dementia and bipolar disorder, who was reported to have been physically restrained by a CNA during personal care. The resident, who had a history of moderate cognitive impairment, alleged that the CNA held his wrist against the bed to prevent him from hitting her coworker during a bed bath, despite his refusal to receive care. The incident was corroborated by the CNA involved, who admitted to holding the resident's wrist down against the bed to prevent him from being combative. The CNA acknowledged that the resident was refusing care and that she should have re-approached the situation or sought assistance from other staff members. The facility's policy on restraints clearly states that physical restraints should not be used for convenience or discipline, and the actions taken by the CNA were not aligned with this policy. Interviews with other staff members, including the DON and Administrator, revealed that the CNAs involved did not follow the proper protocol for handling a resident who was refusing care. The staff should have backed away and re-approached the resident later or involved additional personnel to assist. The failure to adhere to these procedures resulted in the inappropriate use of physical restraint, which violated the resident's rights and could have caused distress or injury.
Inaccurate PASRR Screenings for Residents with Mental Health Disorders
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASRR) screenings for two residents with mental health disorders. Resident #61, a male with PTSD and dementia, was readmitted to the facility without a correct PASRR Level 1 Screening submitted to the local authority. His records inaccurately indicated no evidence of mental illness, despite having active diagnoses of PTSD and depression. The MDS Coordinator acknowledged the error and stated that a Form 1012 should have been completed to correct the PASRR Level 1, but this was not done. Resident #55, a male with bipolar disorder, was admitted to the facility with a primary diagnosis of bipolar disorder. However, his PASRR Level 1 Screening from 2019 indicated no evidence of mental illness, and no PASRR evaluation was completed. It was only after surveyor intervention that a new positive PL1 was submitted, and a Form 1012 was completed. The MDS Coordinator admitted to being confused by the PASRR process and had not conducted a full audit of the resident's charts, only addressing issues brought to her attention by surveyors. The facility's policy on PASRR was not followed, as it requires each resident to be screened for mental disorders or intellectual disabilities prior to admission. The policy states that a negative Level 1 screening permits admission unless a serious mental disorder arises later. The failure to ensure accurate PASRR screenings for these residents could have impacted their ability to receive necessary care and services according to their needs.
Failure to Address PTSD in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident with a PTSD diagnosis, which was not addressed in the care plan upon admission. The resident, a male with a history of military service in the Marines, had a PTSD diagnosis and specific triggers related to his past trauma, such as loud noises and closed doors. These triggers were not included in the baseline care plan, as the trauma assessment was not completed within the required 24-48 hours of admission. This oversight was identified during a surveyor's intervention, which revealed a positive PTSD screen for the resident. Interviews with facility staff, including the social worker and the Director of Nursing (DON), confirmed that the trauma assessment was not completed in a timely manner, and the resident's triggers were not documented in the baseline care plan. The social worker acknowledged the risk posed by this omission, as staff might unknowingly trigger the resident. The DON and the Administrator both expressed that the failure to include the resident's triggers in the care plan placed the resident at risk and hindered the provision of person-centered care.
Failure to Update Care Plans for Isolation and Care Refusal
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental and psychosocial needs. For Resident #49, the facility did not include a care plan for contact isolation despite a diagnosis of Extended-Spectrum Beta-Lactamase (ESBL), a bacteria that can be spread from person to person. The resident's medical records indicated the presence of ESBL, and physician's orders were in place for antibiotics, but the care plan was not updated to reflect the necessary precautions for contact isolation. For Resident #59, the facility did not include in the care plan the resident's refusal of incontinent care and bathing, despite staff being aware of these refusals. The resident had a diagnosis of vascular dementia and was moderately impaired cognitively. Interviews with staff revealed that the resident's refusal of care was known, and efforts were made to involve family members to encourage compliance, but this was not documented in the care plan. The absence of this information in the care plan meant that the staff did not have a documented strategy to address the resident's refusals. The facility's policy required an interdisciplinary team to develop and maintain a comprehensive care plan for each resident, identifying care needs, incorporating risk factors, and establishing measurable goals. However, the process for updating care plans was not effectively implemented, as evidenced by the lack of updates for the two residents. Interviews with staff, including the ADON, MDS nurses, and the Administrator, highlighted a recent change in the process for updating care plans, but this change had not yet resolved the deficiencies identified.
Failure to Change Oxygen Tubing as Scheduled
Penalty
Summary
The facility failed to provide appropriate respiratory care for Resident #105, who required oxygen therapy due to conditions such as chronic obstructive pulmonary disease and heart failure. The deficiency was identified when it was observed that the oxygen tubing for Resident #105 was not changed as per the facility's policy, which mandates weekly changes. Specifically, the tubing was dated 01/22/25 during an observation on 02/03/25, indicating it had not been changed on the scheduled date of 01/29/25. This oversight was confirmed by the treatment administration record, which falsely indicated that the tubing had been changed on 01/29/25. Interviews with facility staff, including the Unit Manager and the Director of Nursing (DON), revealed that the responsibility for changing the oxygen tubing was delegated to the CNAs, with the night shift charge nurses responsible for ensuring compliance. However, the Unit Manager admitted to not verifying the change, and the DON acknowledged that the failure to adhere to the policy placed Resident #105 at risk for respiratory infection or complications. The Administrator also confirmed that the staff did not follow the proper protocol, which could lead to bacterial contamination and infection risks for the resident.
Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to the administration of anti-hypertensive medication without ensuring the residents' blood pressure met the prescribed parameters. Resident #93, a male with a history of atherosclerotic heart disease and hypertension, received Carvedilol on two occasions when his diastolic blood pressure was below the threshold specified in his medication order. Similarly, Resident #114, also with a history of heart disease and hypertension, was administered both Carvedilol and Lisinopril when his diastolic blood pressure was below the prescribed limit. Interviews with facility staff, including LVNs, RNs, the Nurse Practitioner, the DON, and the Administrator, revealed a lack of adherence to medication administration protocols. Staff members acknowledged the importance of withholding medication when blood pressure readings fall outside the ordered parameters to prevent adverse effects such as dizziness and falls. However, the medication was still administered without notifying the physician or nurse practitioner, as required by the facility's policy. The facility's policy on medication administration, which mandates checking the physician's order for direction, was not followed. The DON and Administrator both expressed expectations that medications should be held if blood pressure readings are outside the ordered parameters, yet this was not consistently practiced. The failure to adhere to these protocols placed residents at risk of harm, as indicated by the staff interviews and record reviews.
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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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