Corinth Rehabilitation Suites On The Parkway
Inspection history, citations, penalties and survey trends for this long-term care facility in Corinth, Texas.
- Location
- 3511 Corinth Parkway, Corinth, Texas 76208
- CMS Provider Number
- 676319
- Inspections on file
- 52
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Corinth Rehabilitation Suites On The Parkway during CMS and state inspections, most recent first.
A resident with COPD, dysphagia, prior pneumonitis from aspiration, and a history of choking experienced at least two choking episodes while eating in her room. After the second episode, her diet was downgraded to mechanical soft and speech therapy later discharged her with recommendations for mechanical soft solids, upright posture during and after meals, and occasional supervision with oral intake. These recommendations were not incorporated into the care plan or active orders, and nursing staff and CNAs were not informed that supervision was required. CNAs only provided tray setup while the resident continued to eat in bed in her room without staff supervision, and leadership interviews revealed unclear processes and lack of awareness regarding communication and implementation of therapy recommendations, resulting in the resident not receiving the ordered supervision and positioning precautions during meals.
The facility failed to maintain a functional call light system with reliable audible notification at the nurses’ station, resulting in delayed staff response to resident requests for assistance. In one instance, a resident repeatedly yelled for help while the call light was illuminated but not audible, and the resident reported waiting a prolonged period before an LVN responded and assisted with a transfer that the resident could not complete due to a malfunctioning bed. An RN acknowledged that call lights often illuminated without sounding, and observations showed multiple call lights active in hallways without corresponding audible alarms or accurate display at the call light notification center, which sometimes showed error or “failed” messages. The Maintenance Director reported the system was obsolete, frequently unplugged, and prone to error messages and continuous beeping, and that he had raised these issues with the former DON. These conditions were inconsistent with the facility’s call light policy requiring prompt response and proper use of the system.
A resident with a Foley catheter, colostomy, and complex perineal and sacral wounds was readmitted from the hospital without specific wound care, catheter, or colostomy orders, and the facility did not obtain immediate physician orders for these treatments. The care plan referenced catheter use and treatments per MD orders but did not identify the colostomy, and the April physician order summary lacked Foley and colostomy care orders, with wound care orders not entered until several days later. Nursing notes documented the presence of a wound vac, surgical and graft sites, and intact catheter and colostomy, but staff acknowledged they had not contacted the MD, wound care physician, treatment nurse, or hospital at admission to clarify and obtain necessary orders. The facility’s own policy required confirmation and clarification of physician orders upon admission to ensure immediate care needs were met, but this process was not followed, and staff stated that the absence of admission orders could delay treatments and increase the risk of wound deterioration and infection.
A resident with severe bilateral glaucoma and allergic rhinitis had ordered Dorzolamide and Latanoprost eye drops and Fluticasone nasal spray. An ADON discovered the eye drops were expired, removed them from the cart, and placed both medications on hold in the eMAR without a physician order, family notification, or a defined stop date, resulting in dozens of missed doses over an extended period. Nursing staff reported being told the drops were on hold until replacement arrived and assumed appropriate orders had been obtained, while the MD, hospice, and pharmacy later confirmed no such order existed and hospice did not cover the drops. Separately, a medication aide administered Fluticasone nasal spray without first clearing the resident’s nasal passages, which was identified as preventing delivery of a therapeutic dose. These actions and inactions showed the facility failed to ensure accurate acquisition and administration of medications to meet the resident’s needs.
A resident with severe bilateral open-angle glaucoma and moderately impaired vision had her prescribed glaucoma eye drops (Latanoprost and Dorzolamide) placed on hold by an ADON after the medications were found expired. The ADON removed the drops from the cart, entered open-ended hold orders in the eMAR without a physician’s order, and did not ensure timely reordering or delivery. Floor nurses and a weekend RN supervisor were told the drops were on hold pending pharmacy delivery and assumed appropriate orders and notifications had been obtained, so they did not independently contact the MD, NP, hospice, pharmacy, or family. As a result, the resident missed 25 doses of Latanoprost and 47 doses of Dorzolamide over nearly a month, despite her care plan calling for these medications to control intraocular pressure. The resident noticed the interruption and informed family, who later contacted staff and hospice, revealing that hospice did not cover the drops and that pharmacy had not been asked to refill one of them for an extended period. Interviews with clinical leadership and consultants confirmed there was no physician order for the hold, no stop date, inconsistent discussion in clinical meetings, and no effective follow-up, resulting in a significant medication error.
Surveyors found that staff failed to follow infection control practices for two residents, including one with a calf wound related to a history of blood clot and another with diabetes, chronic hepatitis C, hemiparesis, and a leg wound. A treatment nurse performed a dressing change while triple-gloving for convenience and did not perform hand hygiene between glove changes, contrary to facility policy. In a separate incident, an LVN entered a room posted for Enhanced Barrier Precautions, transferred a resident with a leg dressing from bed to wheelchair and then to the toilet without donning gown or gloves, and left the room without performing hand hygiene, only using sanitizer in the hallway afterward. Facility policies required hand hygiene with glove changes during wound care and use of gown and gloves for residents with wounds during high-contact care such as transfers and toileting.
Two residents did not have all invasive devices and related care reflected in their comprehensive care plans. One resident, admitted post‑sepsis with multiple surgeries and an intact, functioning colostomy, had a care plan that addressed catheter use for wound management and repositioning but did not include the colostomy, its goals, or specific interventions, despite documentation and family reports that colostomy care was being provided. Another resident with encephalopathy, cellulitis, UTI, pressure ulcers, poor oral intake, and failure to thrive had physician orders for a midline catheter, continuous IV normal saline, and scheduled NS flushes, and later had another midline inserted; observation confirmed a midline in place with an intact dressing. However, her care plan, last revised later, did not address the midline catheter or associated care. Staff interviews and facility policy confirmed that devices such as urinary catheters, midlines, and colostomies were expected to be included in person‑centered care plans, but this did not occur for these two residents.
A resident with encephalopathy, cellulitis, UTI, pressure ulcers, and poor nutritional status had a midline IV catheter placed for NS infusion and then ordered to be flushed q12h when not in use. MAR/TAR entries showed ordered flushes were performed by RNs until an agency LVN documented a flush, after which subsequent nursing notes indicated the midline was no longer present, with no clear record of when or how it was removed. Staff interviews revealed that no practitioner order for discontinuation could be located, and there was no documentation of the removal procedure, catheter integrity, or insertion-site assessment, despite facility policy and leadership expectations that a practitioner’s order and full documentation accompany any midline removal.
Surveyors found that medications and biologicals were not fully secured when an insulin pen, lancets, and glucometer strips were left on top of a locked medication cart on a resident hall with no nurse present, while multiple staff walked past. An RN later returned, unlocked the cart, and placed the items inside, acknowledging he had neglected to secure the insulin and that this could allow unauthorized access. The CSD and written policy confirmed that all medications must be stored in locked compartments or a medication room when unattended and accessible only to licensed or authorized staff.
Two residents experienced deficiencies in clinical documentation when staff failed to maintain complete and accurate records of wound care and Foley catheter orders. One resident returned from a hospital stay with multiple wounds and a wound vac, but wound treatments were not consistently documented on the MAR/TAR, and wound care orders were not promptly obtained or entered, despite staff acknowledging that wound care had been provided and, at times, refused. Another resident with an indwelling Foley catheter had a physician order that lacked essential details such as catheter size, balloon volume, and documented rationale for use, even though the care plan referenced urinary retention and UTIs. The facility’s own leadership confirmed that orders and treatment documentation were incomplete and did not meet expected documentation standards.
The facility failed to ensure accurate documentation of controlled substance counts on one medication cart when an LVN did not sign the controlled drug count sheet at shift changes on multiple occasions, despite facility policy requiring counts and signatures at each change of shift. Record review showed missing off-duty and on-duty signatures on several dates for the Hall 100 cart, and the DON confirmed that staff are trained and expected to sign after completing counts together. The LVN reported that she performed the counts but found the count sheet format confusing and did not sign as required, resulting in incomplete documentation of controlled drug accountability.
A resident with multiple chronic conditions and intact cognition had a physician’s order for one 5% Lidocaine patch to be applied to the left hip each morning and removed in the evening. On one morning, a medication aide applied the ordered patch, and shortly afterward an LVN, who was also passing medications, applied a second Lidocaine patch to the same general area after not seeing the first patch, which was positioned higher on the hip and partially covered by briefs. The resident later reported to the DON that staff had applied an additional patch, and the DON and administrator confirmed the presence of two patches, demonstrating a failure to follow the physician’s order and the facility’s medication management policy requiring adherence to the “8 Rights” of medication administration and that the same authorized person prepare, administer, and record medications.
A resident with dementia and hypertension, who required assistance with ADLs and had intact cognition, was observed with long chin hair despite a care plan goal to remain well-groomed and a facility policy to provide necessary grooming care. The resident reported receiving regular showers and repeatedly asking staff to shave her chin hair, but was told there were no razors. Staff interviews revealed that CNAs were responsible for grooming, including facial hair removal for female residents, that disposable razors were available, and that charge nurses were expected to ensure appropriate daily care. The DON confirmed razors were part of grooming supplies and that she had not been informed of the resident’s request, indicating the resident’s grooming needs and expressed preferences for facial hair removal were not met.
A CNA failed to follow infection control practices during incontinence care for a resident with multiple medical conditions, including a femoral neck fracture and generalized muscle weakness. After cleaning the resident’s perineal and buttocks areas, which included a bowel movement, the CNA did not change gloves or perform hand hygiene before applying a clean brief and repositioning the resident. The CNA later acknowledged knowing he should change gloves and perform hand hygiene when moving from dirty to clean tasks but did not do so. The DON confirmed that facility policy and expectations required hand hygiene before and after care and between dirty and clean activities, and the written hand hygiene policy required hand hygiene after contact with soiled items and after glove removal.
Staff failed to follow Enhanced Barrier Precautions and hand hygiene protocols for two residents with infectious disease histories. An LPN and a CNA did not wear gowns during high-contact care for a resident on EBP, and another CNA did not wear a gown or perform hand hygiene between glove changes while providing incontinent care to a different resident. These actions were inconsistent with the residents' care plans, posted signage, and facility policy.
A resident with a history of falls and requiring maximum assistance attempted to transfer independently after staff did not respond to his call light, resulting in a fall and a call to 911 for help. Both the CNA and RN assigned to the resident were on break at the same time, leaving the resident without assigned staff assistance. The DON did not initially interview the resident or contact EMS, and the incident was not self-reported as neglect as required by facility policy.
A resident with a history of falls and requiring maximum assistance for transfers fell while attempting to use the bathroom after staff failed to respond to his call light. Both the CNA and RN assigned to the resident were on break at the same time, leaving the resident without assistance. The resident called 911 for help, and EMS assisted him. The facility did not thoroughly investigate the incident, as the DON did not initially interview the resident or contact EMS, and was unaware that both assigned staff were absent during the fall.
A resident with a history of falls and requiring maximum assistance for transfers fell while attempting to use the bathroom after staff failed to respond to his call light. Both the CNA and RN assigned to the resident were on break at the same time, leaving the resident unsupervised. The resident called 911 for help after the fall, and the DON did not initially interview the resident as part of the investigation.
Several dependent residents did not receive necessary assistance with personal hygiene, including nail care and scheduled showers. Observations found long, dirty fingernails and missed showers, with staff interviews revealing confusion about responsibilities and inconsistent documentation. These failures occurred despite facility policies requiring regular ADL care and monitoring.
A CNA failed to provide timely and appropriate perineal care to a female resident with severe cognitive impairment and incontinence, omitting critical cleaning steps and not performing care as frequently as required by facility policy. The resident was found with wet, reddened skin and soiled bedding, and the CNA admitted to missing care due to being busy. The DON confirmed that proper perineal care, including cleaning the labia, is essential and expected.
The facility did not ensure that RNs responsible for two medication carts consistently counted and signed for controlled substances at each shift change, as required by policy. Record reviews showed missing signatures on narcotic count sheets, and interviews revealed that counts were performed but signatures were omitted due to being busy or misunderstanding procedures. The DON confirmed that both incoming and outgoing nurses are expected to sign immediately after counting.
Surveyors found that food items in the kitchen, including frozen French fries and biscuit dough, were not properly dated, labeled, or covered, and hamburger buns in dry storage lacked required labeling. Staff interviews confirmed that all kitchen staff were responsible for ensuring food items were stored according to policy, but these standards were not met.
Staff failed to disinfect a blood pressure cuff between use on two residents and did not follow proper hand hygiene or PPE protocols during care of a resident on Enhanced Barrier Precautions, including not wearing gowns and not sanitizing hands when changing gloves, despite facility policies and training.
Two residents were permanently discharged without completed discharge summaries in their electronic medical records, despite facility policy requiring interdisciplinary documentation for all permanent discharges. One resident, a respite admission under hospice care, and another with severe cognitive impairment and multiple diagnoses, both lacked the necessary discharge summaries, as confirmed by staff interviews and record review.
A resident with a history of falls and multiple medical conditions experienced a fall in the bathroom. Although the resident was assessed and family notified, the charge nurse did not promptly notify the physician as required by facility policy, only doing so the following day after being instructed. Interviews confirmed the nurse was unaware of the fall notification protocol, resulting in a failure to follow professional standards of practice.
A resident on continuous oxygen therapy did not have their oxygen humidification bottle and nasal cannula tubing changed according to the required weekly schedule, as observed by surveyors. The equipment was found to be overdue for replacement, and staff interviews confirmed that the change had not occurred as per physician orders and facility policy, resulting in a lapse in infection control practices.
A resident with severe cognitive deficit did not receive privacy during insulin administration by an LVN, as captured by a Ring camera. The resident was uncovered and in a vulnerable state, and the privacy curtain was not drawn. The facility's policy on maintaining resident dignity and privacy was not followed, as confirmed by the DON and Administrator.
A resident with moderate cognitive impairment experienced a witnessed fall while under one-to-one observation, leading to an allegation of neglect. Although the incident was reported to Texas Health and Human Services the following day, the facility failed to submit the required investigation report within the five-day timeframe. The previous administrator, responsible for the report, was suspended and later terminated, resulting in a delay that risked timely state review.
A resident with a history of falls was not properly assessed after a witnessed fall in a facility. An LVN failed to conduct an immediate post-fall assessment, including checking vital signs and range of motion, before assisting the resident to the bathroom. The incident was captured on a Ring camera, revealing the LVN's failure to follow the facility's fall management protocol.
An LVN failed to perform hand hygiene and change gloves between administering medications to two residents, as captured by video footage. The residents, both with cognitive impairments and multiple health conditions, were at risk due to this breach in infection control protocols. The DON confirmed the LVN's failure to adhere to the facility's infection control policies.
The facility failed to ensure that residents, family members, and legal representatives had easy access to view the nursing home's survey results. Residents were unaware of the location of the survey results and their right to review them. The Activities Director and Administrator were unclear about the exact location and communication of these results, despite policies indicating that residents should be informed.
The facility failed to investigate allegations of neglect for two residents. One resident experienced an unwitnessed fall resulting in a pelvis fracture, and another had a family member report neglect due to soiled bed sheets. Despite self-reports being made, no investigations were conducted, and staff were not questioned about the incidents.
A facility failed to develop a comprehensive care plan for a resident who stored fresh produce in unsanitary conditions, leading to potential health risks. Despite staff awareness, the care plan did not address the issue, resulting in a lack of coordinated care.
The facility failed to maintain a resident's personal hygiene by not ensuring his fingernails were cleaned and trimmed. The resident, who required maximal assistance due to dementia and other conditions, was found with long, discolored nails. Staff interviews revealed a lapse in daily nail care observation and adherence to the facility's grooming policy.
A facility failed to provide proper perineal care for a resident with incontinence, leading to a risk of urinary tract infections. CNA A did not follow the correct procedure of cleaning from front to back and failed to change gloves or perform hand hygiene when moving from dirty to clean tasks. The resident had multiple diagnoses, including dementia and muscle wasting, and required maximal assistance with personal hygiene.
The facility failed to ensure that medications in unsecure containers were removed from the Med Aide Cart, posing risks of drug diversion and infection control issues. A controlled medication blister pack was found with a broken seal and taped over, and the responsible Med Aide was unaware of the damage.
The facility failed to maintain an infection control program, as a CNA did not perform hand hygiene or change gloves during incontinence care for a resident, and an LVN did not sanitize hands after conducting an FSBS test and cleaning the glucometer before administering insulin to another resident.
Failure to Implement Speech Therapy Choking Precautions and Supervision During Meals
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment free from accident hazards and to provide adequate supervision to prevent accidents for one resident with a history of choking. The resident was an older female with COPD, mild protein-calorie malnutrition, pneumonitis due to inhalation of food and vomit, dysphagia, prior food in the larynx causing asphyxiation, GERD, cognitive communication deficit, and Type 2 diabetes. Her MDS showed intact cognition (BIMS 15), a mechanically altered therapeutic diet, and a need for setup or cleanup assistance with eating. She experienced at least two choking incidents while eating in her room in 2026, including a documented event on 3/7/26 and another on 3/13/26. During the 3/7/26 incident, an agency LVN responded to the room, found the resident sitting upright, red in the face but without cyanosis or respiratory distress, and documented that the resident was able to cough and clear her airway. The LVN noted the resident’s preference to keep her diet the same and attributed the event to the resident talking while eating, notified the nurse practitioner, and documented continued monitoring. On 3/13/26, the ADON responded to another choking episode after a visitor reported the resident was choking. The resident was found in bed at about a 30-degree angle with facial flushing and signs of distress, awake and responsive, with apparent food lodged in her throat. The head of the bed was elevated to about 50 degrees, and within about 30 seconds the resident expelled a half-dollar-sized piece of cauliflower. The ADON notified the charge nurse, speech therapist, and nurse practitioner. Following consultation, the resident’s diet was downgraded to mechanical soft pending further speech evaluation, and a chest x-ray was ordered to rule out aspiration. The care plan was revised on 3/16/26 to include a problem of choking while eating, a goal for safe meal consumption without choking, and approaches such as chest x-ray as ordered, downgrade to mechanical soft diet, ensuring proper positioning prior to meals, and speech therapy assessment and treatment as indicated. However, the care plan did not address the 3/7/26 choking incident and was not revised to include specific discharge recommendations from speech therapy for occasional supervision, upright posture during meals, and upright posture for more than 30 minutes after meals. Speech therapy records showed the resident received services from 1/13/26 to 3/12/26 for cognition and was re-referred on 3/13/26 for the choking episode, with the speech therapist immediately downgrading her diet to mechanical soft and observing her eat that diet 17 times. The speech therapy discharge summary dated 4/21/26 recommended mechanical soft solids, all liquids, general swallow precautions, upright posture during meals and for more than 30 minutes after meals, and occasional supervision for oral intake. These recommendations were not translated into physician orders or incorporated into the resident’s active orders, which only reflected in-room dining preference, setup assistance for eating, and a consistent carb mechanical soft diet with special instructions. Multiple CNAs reported they only set up the resident’s tray, chopped food as needed, and that the resident preferred to eat in bed in her room; they stated they had never supervised her during meals and were unaware of any requirement for supervision, noting she was not on any feeding/supervision list and that no nurse had informed them of such a need. The resident and her roommate both reported that only the speech therapist had watched her eat, and no other staff were present during meals. During a lunch observation, staff delivered and set up the resident’s mechanical soft tray, remained in the room for about two minutes, and then left, with no staff supervising the resident while she ate. Interviews with nursing and therapy leadership revealed gaps in communication and implementation of therapy recommendations: the speech therapist stated he provided the discharge summary with recommendations to the Director of Rehab and expected nursing to provide occasional supervision; the Director of Rehab stated discharge recommendations would be discussed in morning meetings and that it was the ADON or DON’s responsibility to convey them to nurses and CNAs. The ADON, Interim DONs, and other nursing staff reported they were unaware of the resident’s choking history, the 3/7/26 incident, or the need for occasional supervision and upright posture after meals, and the ADON could not initially explain how therapy recommendations were communicated to nursing. The facility’s accident/incident policy required immediate reporting of incidents and ongoing documentation for three days following an incident, but staff interviews indicated that an incident report and referral to speech therapy should have been completed after the first choking incident and that recommendations from therapy should have been communicated via the 24-hour report and in-services, which did not occur. These actions and omissions resulted in the resident not receiving the recommended occasional supervision and specified positioning during and after meals, despite her documented choking episodes and therapy recommendations.
Failure to Maintain Functional Call Light System and Audible Notification
Penalty
Summary
The deficiency involves the facility’s failure to maintain a fully functional call light system that allowed residents to reliably summon staff assistance from their rooms, bathrooms, and bathing areas, and to ensure that calls were audibly signaled at a centralized staff work area. During an observation, a resident was heard repeatedly yelling for help while the call light above the room door was illuminated but produced no audible sound. A nurse entered the room and told the resident to stop yelling; the resident reported he had been waiting 45 minutes for assistance, while the nurse disputed the length of time. The nurse then assisted the resident from bed to wheelchair and into the bathroom and discovered the bed would not raise to chair level, which had prevented the resident from transferring independently. In a separate interview, an RN stated that he answered call lights when he noticed them illuminated but confirmed that the system’s audible function at the nurses’ station was inconsistent, sometimes working and sometimes not, and he did not know how long it had been that way. Later observation at the nurses’ station showed multiple call lights illuminated down a hallway with no audible alarm sounding at the call light notification center. The Administrator identified that the notification center phone cord was not fully plugged in; once it was pushed in, the system began to sound audibly and display room numbers. Additional observation showed the notification center sounding for two call lights while no corresponding lights were illuminated in the hallway, and the notification center displayed a “failed” message. On another occasion, a call light on one hall was visibly illuminated, but the notification center did not show any information for that hall. The Maintenance Director reported that the call light system was obsolete, that parts were no longer available to keep it fully operational, and that it was not uncommon to find the system unplugged. He stated the system displayed error messages and continuously beeped, requiring staff to pick up and replace the phone to reset it, which he believed led staff to unplug the phone. He also stated he had gone to the former DON several times about these concerns. A resident later stated that while he usually did not need to call for help, when he did, staff sometimes took a long time to respond, occasionally over an hour. The facility’s written Call Lights Policy required staff to respond to call lights as quickly as practicable, respond to emergency lights immediately, and not cancel call lights until the resident’s needs had been addressed, but the observed malfunctioning and inconsistent operation of the call light system conflicted with these policy requirements.
Failure to Obtain Immediate Physician Orders for Foley, Colostomy, and Wound Care on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement physician orders for a resident’s immediate care upon readmission, specifically for a Foley catheter, colostomy, and complex wound care. The resident was an adult male, cognitively intact with a BIMS score of 15, who had a urinary catheter, a colostomy, and abscesses in the groin and perineal areas. His care plan identified him as a new admission post-sepsis with goals to identify immediate health and safety needs and approaches that included catheter use for wound management, turning and repositioning, and treatments per physician orders; however, the colostomy was not identified in the care plan. The hospital discharge orders did not contain specific orders for wound care, Foley catheter care, or colostomy care, and only instructed that detailed wound care instructions be sent with the patient and that the wound vac be continued in the skilled nursing facility, along with a recommendation for frequent repositioning and pressure offloading. Record review showed that the resident’s April physician order summary contained no orders for urinary catheter or colostomy care, and wound care orders were not entered until several days after readmission. Nursing progress notes documented that the resident returned from the hospital with a wound vac in place and that the initial skin and systems assessment was deferred at the time of arrival. A later skin assessment documented surgical wounds to the coccyx, additional wounds on the perineum and scrotum, a skin-grafted site on the right upper leg, and suture markings on both upper inner thighs, as well as the dates of the last Foley and colostomy bag changes. Subsequent nursing notes described the resident’s colostomy and indwelling catheter as intact and noted the wound vac settings, but there were still no corresponding physician orders for catheter or colostomy care at that time. Interviews with staff confirmed that no wound care, Foley catheter, or colostomy care orders were obtained at the time of readmission. The treatment nurse stated that the hospital had not sent wound care orders and that she later obtained wound care orders from the facility’s wound care physician to resume previous orders, and then separately obtained wound vac orders, acknowledging that she should have restarted prior orders sooner. She also stated that the resident did receive wound care on two days that was not documented. The admitting RN reported that he did not think to call the physician to restart previous wound, urinary catheter, or colostomy orders, did not know who the wound care physician was, and did not contact the treatment nurse or the hospital to obtain orders. The clinical services director stated it was the facility’s expectation that any admitted resident must have orders for necessary care, including wound, urinary catheter, and colostomy care, and that daily orders needed to be clarified immediately. The facility’s own policy on physician orders required that a nurse review transfer records, call the physician to confirm and request additional orders as needed, and ensure that upon admission the facility had physician orders for the resident’s immediate care, but this process was not followed for this resident. The report states that this failure to have physician orders for the resident’s Foley catheter, colostomy, and wound care upon readmission could place the resident at risk for not receiving appropriate care and treatment services. The treatment nurse further stated that the risk of not having orders upon admission was that wounds might not receive treatment and could decline or become infected, and that colostomy and urinary catheter care could be missed, increasing the risk of infections. The clinical services director similarly stated that not having admission orders could delay treatments and result in a decline in the resident’s overall well-being and recovery.
Unauthorized Medication Hold and Improper Nasal Spray Administration
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pharmaceutical services and to ensure medications were accurately acquired and administered for a resident with glaucoma and allergic rhinitis. The resident was an older female with bilateral primary open-angle glaucoma, multiple sclerosis, and allergic rhinitis, with moderately impaired vision and moderate cognitive impairment. Her active physician orders included Dorzolamide 2% ophthalmic drops twice daily, Latanoprost 0.005% ophthalmic drops once daily, and Fluticasone nasal spray twice daily. Her care plan directed staff to administer eye medications as ordered and at appropriate times to manage ocular pressure related to glaucoma. The facility’s Assistant Director of Nursing (ADON) identified that the resident’s glaucoma eye drops were expired while performing a medication cart audit on a night shift. The ADON removed the eye drops from the cart, discarded them, and unilaterally placed both Dorzolamide and Latanoprost on hold in the electronic MAR without obtaining a physician’s order, without documenting any physician order for the hold, and without notifying the physician or the resident’s family. The MAR showed that Dorzolamide was on hold for an extended period, resulting in 47 missed doses, and Latanoprost was on hold for a similar period, resulting in 25 missed doses. There was no order indicating when these medications were to be held or restarted, and the hold was entered as open-ended with no stop date. Multiple nurses and medication aides reported that they were told by the ADON that the eye drops were on hold until the medications arrived from the pharmacy and that they believed the necessary physician orders and notifications had been obtained. Staff stated they repeatedly saw the medications listed as on hold and reported this in clinical meetings or to supervisors, but no effective follow-up occurred to secure the medications or clarify orders. The physician, hospice nurse, and pharmacy later confirmed there had been no physician order to hold the medications and that hospice did not cover the glaucoma drops. Interviews with the Interim DON, Clinical Services Director, Administrator, and pharmacy consultant confirmed that the ADON, who was responsible for pharmacy systems and on-call clinical oversight, placed the medications on hold without a physician’s order, failed to follow up to obtain the medications, and did not ensure the resident received the prescribed glaucoma therapy for nearly a month. In addition, the facility failed to ensure proper administration technique for the resident’s Fluticasone nasal spray. A medication aide did not clear the resident’s nasal passages before administering the nasal spray, contrary to appropriate administration procedures. This failure was identified as placing residents at risk of not receiving a therapeutic dosage of the medication. The combined failures—unauthorized and prolonged holding of critical glaucoma medications and improper nasal spray administration technique—demonstrated that the facility did not provide pharmaceutical services that assured accurate acquiring and administering of medications to meet the resident’s needs.
Glaucoma Eye Drops Inappropriately Held Without Orders, Leading to Prolonged Missed Doses
Penalty
Summary
The deficiency involves a resident with bilateral primary open-angle glaucoma whose prescribed glaucoma eye drops were placed on hold without a physician’s order, resulting in numerous missed doses over an extended period. The resident, an older female with severe stage bilateral glaucoma and moderately impaired vision, had active diagnoses of unspecified open-angle glaucoma and used corrective lenses. Her care plan included administration of glaucoma medications (Latanoprost 0.005% once daily and Dorzolamide 2% twice daily) as ordered to relieve or minimize ocular pressure. During a night-shift medication cart audit, an ADON identified that the resident’s glaucoma eye drops were expired, removed them from the cart, and unilaterally placed both medications on hold in the electronic MAR without obtaining a physician’s order, documenting that the medications were on hold pending refill from hospice pharmacy. Following this action, the resident’s Latanoprost was on hold for a period during which 25 doses were missed, and Dorzolamide was on hold for a longer period during which 47 doses were missed. Multiple nurses, including LVNs and the weekend RN supervisor, reported that they were told by the ADON that the medications were on hold due to expiration and pending delivery, and they assumed that appropriate physician orders and notifications had been obtained because the ADON had executed the hold. The hold orders were entered without a stop date, and there was no documentation that the physician, NP, hospice, pharmacy, or the resident’s family had been notified at the time the medications were placed on hold. Staff interviews indicated that the eye drops’ unavailability and hold status were mentioned intermittently in morning clinical meetings and 24-hour reports, but there was no effective follow-through to secure replacement medications or clarify orders, and the medications remained on hold for nearly a month. The resident herself noticed that she was not receiving her usual glaucoma eye drops and reported this to her family member. The family member later contacted facility staff and hospice, expressing concern about the interruption in therapy and lack of communication. Subsequent review of records and interviews confirmed that hospice did not cover the glaucoma medications and had not been previously notified of any change, that the facility pharmacy had delivered Dorzolamide earlier than staff realized, and that Latanoprost had not been requested for refill for an extended period. The physician and MD later reported they had not been notified when the medications were placed on hold, and the ophthalmology office confirmed the resident’s glaucoma was severe and that the prescribed drops were intended to keep intraocular pressure down and prevent further optic nerve damage. The facility’s internal investigation and staff statements consistently showed that the ADON placed the medications on hold without a physician’s order, failed to follow up to ensure timely reordering and delivery, and that floor nurses relied on the ADON’s actions and did not independently obtain orders or restart the medications, resulting in the resident missing a significant number of prescribed glaucoma medication doses. Additional interviews with the Interim DON, Clinical Services Director, pharmacy consultant, hospice nurse, and other staff further detailed the sequence of inactions that led to the prolonged interruption of therapy. The Interim DON and CSD stated that any medication placed on hold should have an associated physician order, with clear start/stop parameters, and should be tracked via reports and discussed in clinical meetings until resolved. They reported that in this case, the hold orders for the glaucoma drops lacked a physician order and stop date, and the issue was not consistently or effectively addressed in daily clinical oversight. The hospice nurse reported learning of the discontinuation only after a family call and stated that the ADON acknowledged placing the drops on hold and forgetting to follow up. The MD and pharmacy consultant explained that failure to receive glaucoma medications could allow intraocular pressure to increase and glaucoma to progress, and the ophthalmology assistant emphasized that once vision loss occurs from glaucoma, it is permanent. Collectively, the documentation and interviews show that the resident was not kept free from significant medication errors because her essential glaucoma medications were inappropriately held without medical authorization and without timely follow-up, leading to a prolonged period in which she did not receive the prescribed therapy. Throughout this period, multiple staff members, including LVNs, the weekend RN supervisor, and a medication aide, were aware that the eye drops were on hold and unavailable, but they either believed the ADON had already obtained necessary orders or lacked authority to change the hold status. The resident’s family member and hospice nurse ultimately brought the issue to higher-level attention after discovering that the resident had gone without her glaucoma medications for nearly a month. Interviews with the Administrator and Interim DON confirmed that they were not promptly informed when the family first raised concerns over a weekend, and that the ADON, who was responsible for pharmacy systems and medication availability, did not ensure that the medications were reordered, delivered, and restarted. As a result, the resident missed dozens of doses of both Latanoprost and Dorzolamide, contrary to her care plan and physician’s original orders, constituting a significant medication error. The report also documents that the resident did not report pain, blurry vision, or noticeable vision loss during the period without eye drops, and that she continued to use glasses for near and far vision. However, clinical experts interviewed in the report noted that glaucoma is often asymptomatic, that increased intraocular pressure is not felt by the patient, and that progression of glaucoma and associated vision loss can occur over time without obvious symptoms. The facility’s own clinical leadership and external consultants characterized the interruption of glaucoma therapy as a serious concern, and the Clinical Services Director stated she would consider the situation a form of neglect. The deficiency is therefore based on the facility’s failure to ensure that the resident was free from significant medication errors by allowing her prescribed glaucoma medications to be held without proper authorization or follow-up, resulting in a prolonged lapse in treatment.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and use of personal protective equipment (PPE) during resident care. For one resident, an older female with a history of acute embolism and thrombosis of the right tibial vein who had been receiving anticoagulant injections and had a wound on the back of her right calf, the Treatment Nurse did not follow proper hand hygiene procedures during wound care. The nurse prepared wound care supplies at the treatment cart, performed hand hygiene, donned a gown, and then put on three pairs of gloves on each hand before entering the resident’s room. During the dressing change, the nurse removed the old dressing from a wound with moderate blood-tinged drainage, then sequentially removed glove layers between steps of cleansing the wound and applying calcium alginate and a dry dressing, but did not perform hand hygiene between glove changes. In an interview following the observation, the Treatment Nurse acknowledged that she was supposed to perform hand hygiene before and after wound care and after glove changes, and admitted that she had triple-gloved for her own convenience. She further stated that she should not have triple-gloved and identified that the risk to the resident was spread of infection. The facility’s policy on performing a dressing change required staff to wash hands before and after donning gloves, to change gloves at specific points in the procedure, and to remove gloves at the end, indicating that hand hygiene and proper glove use were expected components of wound care. The deficiency also includes failure to implement Enhanced Barrier Precautions and proper hand hygiene for a male resident with type 2 diabetes mellitus, chronic viral hepatitis C, hemiparesis, and a leg wound treated daily. An LVN responded to the resident’s call for help, entered the room where an Enhanced Barrier Precautions sign and PPE cart were present, and transferred the resident from bed to wheelchair and then to the toilet without donning gloves or a gown. The LVN then left the room without performing hand hygiene and only used hand sanitizer from a hallway dispenser afterward. In an interview, the LVN stated she was unsure whether the resident was on Enhanced Barrier Precautions, acknowledged that residents with bandages might require such precautions, and admitted uncertainty about gown use and the specifics of Enhanced Barrier Precautions. Facility policy on Transmission Based/Standard Precautions and Enhanced Barrier Precautions required gowns and gloves for residents with wounds or indwelling devices during high-contact care activities such as transferring and assisting with toileting, and the Clinical Service Director confirmed that staff were expected to change gloves and perform hand hygiene during wound care and to use gown and gloves for residents with wounds during high-contact care.
Failure to Include Colostomy and Midline Catheter in Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and update comprehensive care plans that described all services to be furnished to meet residents’ needs. For one male resident admitted and readmitted after hospitalization for sepsis and multiple surgeries, including creation of a colostomy, the 5‑day MDS showed intact cognition, a urinary catheter, a colostomy, and groin/perineal abscesses. His care plan, completed shortly after admission, identified him as a new admission post‑sepsis with goals to identify immediate health and safety needs and included approaches such as catheter use for wound management, turning and repositioning, and treatments per physician orders. However, the care plan did not address his colostomy, associated goals, or specific interventions, despite documentation on admission that he had an intact, functioning colostomy and family reports that he had undergone multiple surgeries and skin grafts and was receiving colostomy care at the facility. For a female resident with diagnoses including encephalopathy, cellulitis, UTI, and pressure ulcers, the admission MDS reflected moderately impaired cognition, a Foley catheter, bowel incontinence, and no IV therapy while a resident. Physician orders later documented initiation of a midline catheter for long‑term IV fluid infusion, including orders for 3 liters of normal saline at a continuous rate, ongoing flushes every 12 hours to maintain patency, and a subsequent order to start another PICC/midline for IV infusion. Nursing staff reported that the midline was placed due to poor oral intake and failure to thrive, that it remained patent and was flushed per orders, that it was found to be no longer present on a later shift, and that another midline was inserted for additional fluids. Observation confirmed the resident had a midline in the upper arm with a clean, dry, intact dressing. Despite these clinical circumstances and active physician orders, the resident’s care plan last revised in mid‑April did not address the presence of the midline catheter or related care and interventions. Interviews with the MDS nurse and Clinical Service Director confirmed that MDS coordinators, DON, ADONs, and floor nurses shared responsibility for initiating and updating comprehensive and baseline care plans, and that devices such as urinary catheters, midline catheters, and colostomies should be care planned to address resident needs and interventions. The facility’s written policy on the care plan process stated that a comprehensive, person‑centered care plan would be developed and implemented for each resident, including instructions needed to provide effective care that meets professional standards of quality, but this was not followed for the two residents’ colostomy and midline catheter.
Failure to Obtain Order and Document Midline IV Catheter Removal
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral fluids and a midline IV catheter were managed and discontinued according to physician orders and professional standards for one resident. The resident was an elderly female admitted with encephalopathy, cellulitis, UTI, pressure ulcers, poor nutrition, failure to thrive, and wounds. A midline catheter was ordered for long-term IV fluid infusion, with 3 liters of 0.9% sodium chloride at 80 ml/hr and subsequent orders to flush the peripheral line every 12 hours when not in use. The MAR/TAR showed the midline was flushed as ordered from early April through midday on the 3rd by regular RNs, and on the morning of the 4th an agency LVN documented a flush for the midnight dose. Following this, nursing documentation reflected that on 04/04 there was a late entry note on 04/05 by an agency LVN stating “No midline is noted,” and on 04/06 an RN documented that the midline in the right upper arm was no longer present. The RN noted that the resident had completed her course of antibiotics on 04/03 and that the NP was contacted and ordered discontinuation of the midline at that time, but there was no prior order documented to remove the line on 04/04 when it apparently came out. Interviews with staff indicated that when the RN returned to work on 04/06, he was informed by another nurse that the midline was not present and that they believed an agency LVN may have discontinued it, but they could not confirm this and could not locate any order authorizing removal of the midline. Staff interviews further established that nurses were expected to obtain a practitioner’s order before discontinuing a midline, and to document the removal procedure, including whether the catheter was intact, the condition of the insertion site, and how the resident tolerated the procedure. Both the RN and another RN working nights stated they were unable to find an order to discontinue the midline and confirmed that such an order and documentation were required. The Clinical Service Director stated her expectation that nurses check midlines every shift, follow physician orders for flushing, and document completion of procedures, including removal and assessment of catheter integrity and insertion site. Review of the facility’s procedure for removing PICC lines specified verifying practitioner orders to discontinue the catheter, assessing catheter integrity, and documenting the procedure, which was not reflected in the record for this resident’s midline removal.
Unsecured Insulin and Supplies Left on Locked Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all drugs and biologicals were stored in locked compartments when unattended, as required by facility policy and professional standards. During an observation on 04/15/2026 at 12:02 PM, the 100 Hall nurse medication cart was found with an insulin pen, lancets, and glucometer strips sitting out on top of the cart. Although the medication cart itself was locked, there was no nurse or staff member present at the cart, and four different staff members were observed walking past it while the medications and supplies remained unsecured on top. At 12:09 PM the same day, an RN was observed returning from a resident room, approaching the 100 Hall medication cart, unlocking it, and then placing the insulin pen, lancets, and glucometer strips into the top drawer. During interview, the RN stated that facility policy required the medication cart to be locked and secured 100% of the time when unattended and stated he never left medications out on top of the cart, but then acknowledged he had neglected to place the insulin pen back in the cart and that failing to put away medications could result in someone having access to them. In a separate interview, the CSD confirmed that facility policy required all medications to be locked inside a medication cart or medication room when unattended and that no medications should be left on top of the cart. Review of the Medication Storage policy dated 04/17/2024 further confirmed that all drugs and biologicals must be stored in locked compartments and accessible only to licensed nursing personnel, pharmacy personnel, or authorized staff members.
Incomplete Wound Care and Foley Catheter Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and systematically organized medical records in accordance with accepted professional standards for two residents. For the first resident, a cognitively intact male with a urinary catheter, colostomy, and perineal/groin abscess, documentation gaps occurred following his readmission from the hospital. Progress notes showed he returned with a perineal abscess wound complication and that a skin assessment identified a surgical wound to the coccyx, another wound on the perineum and scrotum, and a skin-grafted site on the right upper leg with reddened areas and sutures on both upper inner thighs. However, there was no documentation of what specific wound treatments were provided at that time. Record review revealed no evidence in the electronic record that wound care was provided or declined on one date, and although a progress note documented that the resident deferred wound care on another date, there were still no corresponding treatment entries on the MAR/TAR because wound care orders had not been entered. A late entry by the treatment nurse documented that the wound vac was in place and functioning and that the physician had assessed the peri/groin incisions and reinstated previous orders, but there remained no MAR/TAR documentation showing wound care provided or declined on additional dates. Interviews with the treatment nurse and RN involved in the admission confirmed that wound care had been performed on certain days but was not documented, and that the admitting nurse did not obtain or enter wound care orders from the hospital or the wound care physician in a timely manner. For the second resident, a moderately cognitively impaired female with diagnoses including encephalopathy, cellulitis, UTI, and pressure ulcers, the facility failed to ensure that the physician’s order for an indwelling Foley catheter was complete. The care plan indicated the resident required an indwelling urinary catheter related to urinary retention and UTIs, but the physician order history showed a standing order for an indwelling Foley catheter with blank fields for catheter size (Fr), balloon volume (cc), and diagnosis/rationale. An additional order allowed catheter changes as needed for obstruction or dislodging, but still did not specify catheter size or balloon volume. The Clinical Services Director stated that residents must have clear orders, including catheter size and bulb size, and that treatments provided must be documented on the MAR/TAR, acknowledging that the existing documentation for this resident’s Foley catheter was incomplete and not in line with the facility’s documentation policy.
Failure to Document Controlled Drug Shift Counts on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper pharmaceutical services and controlled substance accountability on one of four medication carts reviewed, specifically the Medication Cart on Hall 100. Record review of the controlled medication count sheet for this cart showed missing signatures for both off-duty and on-duty nurses at shift changes on four separate dates (02/03/26, 02/06/26, 02/08/26, and 02/12/26). The facility’s policy, dated 01/15/25 and titled “Medication Management Program,” requires that controlled substances be counted by authorized staff at each change of shift and accounted for on a controlled substance record. The absence of required signatures indicated that the facility did not consistently document that these counts were completed as required. During interviews, the DON stated that staff were trained to perform controlled drug counts at the beginning and end of their shifts on their assigned medication carts and that nurses were expected to sign the medication count sheet after completing the count with the incoming or off-going nurse. The DON also stated that missing signatures meant she could not prove that the staff had successfully completed the counts. An LVN assigned to the Hall 100 cart acknowledged that she did not sign the medication count sheet on the identified dates, explaining that she found the layout of the sheet confusing because she had to sign on different sides and lines when signing on and off. She stated that she understood the importance of signing the sheet as proof that the count was done and reported that she did perform the counts as required, but failed to document them with her signature.
Double Application of Lidocaine Patch Contrary to Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer medication according to a physician’s order when a resident received two Lidocaine (Lidoderm) patches instead of the prescribed single patch. The resident was an adult male with multiple diagnoses including HIV, seizures, neuromuscular dysfunction, paraplegia, hypertension, depression, anxiety, and other conditions, and had an intact cognition with a BIMS score of 15. A physician’s order dated 01/04/26 directed that one 5% Lidocaine patch be applied topically to the left hip at 9:00 AM and removed at 9:00 PM. On 01/16/2026, the Medication Administration Record showed that a medication aide administered the ordered Lidocaine patch to the resident at 9:00 AM, and the aide later stated that when she applied the patch, the resident did not already have one on. Shortly thereafter, an LVN, who was also passing medications, applied an additional Lidocaine patch to the resident’s left lower hip area. The LVN reported that she had given the resident his medications, left to obtain the Lidocaine patch, and upon returning did not see an existing patch, which she stated must have been applied in the interim. She further stated that the resident, who was verbal and able to direct where he wanted the patch placed, did not inform her that a patch had just been applied. The situation was discovered when the resident reported to the DON that staff had applied an additional Lidocaine patch. The DON and the administrator both confirmed that the resident had two Lidocaine patches on his left hip, with one patch located higher up and partially covered by the resident’s briefs. The LVN later found the first patch higher on the left hip than where she had placed the second patch and stated that the patch may have moved or been moved by the resident. The facility’s Medication Management Program policy required adherence to the “8 Rights” of medication administration and specified that the same authorized person should prepare, administer, and record medications, but in this instance, two different staff members applied Lidocaine patches, resulting in a double application contrary to the physician’s order.
Failure to Provide Grooming Assistance for Facial Hair Removal
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for one resident. The resident was an older female with non-Alzheimer’s dementia and hypertension whose Quarterly MDS showed a BIMS score of 13, indicating intact cognition, and a need for partial/moderate assistance with showering/bathing. Her care plan, revised 12/10/25, documented that she required assistance with ADLs related to visual impairment, weakness, and impaired cognition, with a goal to remain clean, dry, odor-free, and well-groomed, and an approach indicating extensive to total one-person assistance with bathing. On observation, the resident was seen sitting at the edge of her bed with scattered chin hair approximately 3/4 inch long. She reported receiving regular showers on a Monday-Wednesday-Friday schedule and stated she had been asking staff to shave her chin hair, but was told that, per facility policy, there were no razors in the facility. She reported feeling embarrassed, avoiding leaving her room, eating in her room, and not going to the dining room because of her facial hair. Interviews with staff confirmed that CNAs were responsible for showers and grooming, including facial hair removal for female residents, and that the facility did have disposable razors for resident use. LVN B stated that CNAs should inspect and trim or shave female residents’ facial hair weekly on shower days according to resident preference, and that charge nurses were responsible for ensuring residents received appropriate and consistent daily care. CNA A stated CNAs were responsible for shaving/removing facial hair on shower days and as needed, and acknowledged the facility had disposable razors, adding that he did not know who told the resident that the facility did not have razors. The DON stated CNAs were supposed to shave/remove female residents’ facial hair on shower days or as desired by the resident, confirmed that razors were part of residents’ grooming supplies, and stated she had not been notified that this resident had facial hair and wanted to be shaved. The facility’s “Activities of Daily Living, Optimal Function” policy stated the facility provides necessary care to residents unable to carry out ADLs to ensure they maintain proper grooming and hygiene. Despite this policy and the resident’s care plan, the resident’s request for facial hair removal was not carried out, resulting in unaddressed grooming needs on the date of observation.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The deficiency involves a failure to maintain proper infection prevention and control practices during incontinence care for one resident. The resident was an older female with diagnoses including hypertension, a left femoral neck fracture, muscle wasting and atrophy, and generalized muscle weakness. Her Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and she was frequently incontinent of bladder. During an observation of incontinence care, a CNA entered the resident’s room, performed hand hygiene, and donned gloves. He unfastened the resident’s brief and cleaned the front pubic area with peri wipes, then assisted her onto her left side, removed and discarded the soiled brief, and cleaned the buttocks area, during which a medium bowel movement was present. After completing cleaning of the soiled areas, the CNA did not change gloves before proceeding to place a clean brief under the resident, reposition her onto her back, fasten the clean brief, cover her, and lower the bed. He then gathered dirty clothes and trash, removed his gloves, performed hand hygiene, and exited the room. In an interview, the CNA acknowledged he was supposed to change gloves and perform hand hygiene each time he moved from a dirty to a clean area during care and stated he did not do so because he was nervous about being observed. The DON confirmed that staff were expected to perform hand hygiene before and after care and to change gloves and perform hand hygiene between dirty and clean tasks, as the hands are considered dirty after cleaning the resident. The facility’s hand hygiene policy required hand hygiene after contact with soiled or contaminated articles and after removal of gloves.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents on Enhanced Barrier Precautions (EBP). For one resident with a history of multidrug-resistant organism (MDRO), both an LPN and a CNA entered the resident's room to assist with a mechanical lift transfer and other care activities without donning required gowns, although they wore gloves and performed some hand hygiene. The resident's care plan and EBP signage indicated that gowns and gloves were required for close contact care, but staff did not comply. The LPN acknowledged that transferring and adjusting the resident, as well as changing oxygen equipment, constituted high-contact care requiring full PPE, and the CNA stated she only wore a gown during showers, not for other care activities. For another resident with a history of ESBL in urine, a CNA performed incontinent care without wearing a gown and failed to perform hand hygiene between glove changes. The CNA wore gloves but did not sanitize hands between glove changes, despite handling soiled briefs and cleaning the resident. The CNA later stated she misunderstood the EBP signage, believing it applied to the roommate, and noted that the hand sanitizer dispenser was outside the room. The resident's care plan and facility policy required proper PPE use and hand hygiene for all staff providing care to residents on EBP. Interviews with the ADON, who also served as the Infection Preventionist, and the DON confirmed that their expectations were for staff to wear appropriate PPE and perform hand hygiene during all close contact care for residents on EBP. Facility policies reviewed also required hand hygiene before and after resident contact and after glove removal, as well as adherence to PPE requirements based on transmission-based precautions.
Failure to Timely Report and Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to ensure timely reporting and investigation of an allegation of neglect involving a male resident with intact cognition, multiple diagnoses including unsteadiness on feet, and a high risk for falls. The resident, who required maximum assistance for transfers, fell in the bathroom after attempting to transfer independently when staff did not respond to his call light. He subsequently called 911 for assistance, and emergency medical services helped him back into his wheelchair. Documentation indicated that the resident's call light was within reach, but he did not use it to call for help before transferring; however, during interview, the resident stated he had pressed the call light and waited as long as he could before attempting to transfer on his own due to lack of staff response. Interviews and record reviews revealed that both the CNA and RN assigned to the resident were on break at the same time, leaving the resident without assigned staff assistance. Other staff members were present in the building, but not assigned to the resident's hall. The Director of Nursing (DON) investigated the fall by speaking to staff but did not interview the resident initially, nor did she contact EMS for additional information. The DON was unaware that both assigned staff were on break simultaneously and did not self-report the incident as neglect because she did not realize the full circumstances at the time. The facility's policy requires immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, to the administrator and appropriate authorities. In this case, the incident was not self-reported as neglect, and the required investigation steps, including interviewing the resident and contacting EMS, were not completed in a timely manner. The administrator later acknowledged that if she had known both assigned staff were on break, she would have self-reported the incident as neglect.
Failure to Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a male resident with intact cognitive ability, who was at risk for falls due to immobility, muscle weakness, diabetes, and chronic pain. The resident required maximum assistance for transfers and had a care plan intervention to keep the call light within reach at all times. On the night of the incident, the resident attempted to transfer from his wheelchair to the toilet independently after waiting for staff assistance that did not arrive, resulting in a fall. He called 911 for help, and emergency personnel assisted him back into his wheelchair. Documentation indicated that the resident was alert, oriented, and had no injuries, but staff education was provided regarding the use of the call light system. Interviews and record reviews revealed that both the CNA and RN assigned to the resident were on break at the same time when the fall occurred, leaving the resident without immediate assistance. The resident reported pressing his call light and waiting as long as he could before attempting the transfer himself. He also stated that he yelled for help after falling, but no staff responded, prompting him to call 911. Other staff confirmed that the assigned CNA and RN were outside on break, and the DON was unaware that both were absent from the unit simultaneously. The facility's investigation into the incident was incomplete, as the DON did not initially interview the resident or contact EMS for additional information. The DON relied on staff accounts and did not recognize the need to self-report the incident as neglect, as she was unaware that both assigned staff were on break at the same time. The facility policy required prompt investigation of any allegations of abuse, neglect, or mistreatment, but this was not fully carried out in this case.
Failure to Provide Adequate Supervision and Timely Assistance Leads to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who was at risk for falls. The resident, a male with intact cognitive ability, non-Alzheimer's disease, unsteadiness on his feet, and requiring maximum assistance for transfers, was found on the bathroom floor after attempting to transfer independently from his electric wheelchair to the toilet. The resident's care plan identified him as a fall risk due to immobility, muscle weakness, diabetes, and chronic pain, and included interventions such as keeping the call light within reach at all times. On the night of the incident, the resident reported pressing his call light to request assistance to use the bathroom but stated that staff did not respond in a timely manner. After waiting as long as he could, he attempted the transfer himself, resulting in a fall. The resident then called 911 for help, as no staff responded to his calls for assistance after the fall. Emergency medical services arrived and assisted him back into his wheelchair. At the time, both the CNA and nurse assigned to the resident's hall were on break simultaneously, leaving the resident without adequate supervision. Interviews with staff and the DON revealed that staff were not supposed to take breaks at the same time, but both the CNA and RN assigned to the resident were outside on break when the fall occurred. The DON did not initially interview the resident as part of the fall investigation and was unaware that the resident had called for help and received no response. The facility's fall management policy required identification of fall risks, planning and implementation of interventions, and thorough investigation of falls, including interviewing the resident and staff, but these steps were not fully followed in this case.
Failure to Provide Necessary ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene, for several residents who were dependent on staff for these tasks. Multiple residents with severe cognitive impairment, physical disabilities, or blindness were observed to have long, dirty, and untrimmed fingernails. In several cases, residents expressed that they could not trim their own nails and wanted staff assistance, but their needs were not met. Staff interviews revealed confusion about responsibilities for nail care, particularly for diabetic residents, and a lack of awareness regarding the condition of residents' nails. Additionally, the facility did not consistently provide scheduled showers or baths for a resident who was totally dependent on staff for bathing and personal hygiene. Documentation showed that this resident missed multiple scheduled showers, with no records of refusals or alternative care being provided. Staff interviews indicated that showers and refusals were supposed to be documented and reported to the charge nurse, but this process was not consistently followed. The resident confirmed that she had not received showers for an extended period and wanted to be showered. Record reviews and staff interviews further highlighted that the facility's policies required daily observation and as-needed care for personal hygiene, including nail care and bathing. However, there was a lack of adherence to these policies, as evidenced by the missed care and inconsistent documentation. The failures in providing necessary ADL care were observed directly by surveyors and confirmed through interviews with residents and staff.
Failure to Provide Timely and Appropriate Perineal Care for Incontinent Resident
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide timely and appropriate perineal care to a female resident who was always incontinent of urine and bowel. The resident, who had diagnoses including Down syndrome, dementia, and a severe cognitive communication deficit, required moderate assistance with toileting and personal hygiene. During an observation, the CNA did not separate the resident's labia while cleaning, missing a critical step in perineal care, and the resident was found to have soaked through her brief and bed sheet, with her skin noted to be wet and red but intact. The CNA admitted to missing this step and acknowledged its importance in preventing infection. Further review revealed that the CNA had not provided any incontinent care to the resident since the start of her shift, despite facility policy and the resident's care plan requiring incontinence care after each episode and at least every two hours. The CNA stated she was busy and had not yet checked on the resident. The Director of Nursing confirmed that proper perineal care, including cleaning the labia, is expected and that failure to do so places residents at risk. Facility policy and CDC guidelines emphasize the importance of good perineal hygiene to prevent urinary tract infections.
Failure to Document Controlled Substance Counts at Shift Change
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for two medication carts (Hall 200 and Hall 300) out of four reviewed. Specifically, the responsible RNs did not consistently count controlled drugs at every change of shift and did not sign the narcotic sheet form after the count, as required by facility policy. Record reviews revealed multiple dates with missing signatures for both off-duty and on-duty nurses on the narcotic count sheets for both medication carts. Interviews with the involved RNs confirmed that the counts were performed but the required signatures were omitted, either due to being busy or misunderstanding the policy. One RN was new and had only recently received in-service training on the correct procedure. The DON confirmed that the expectation is for both incoming and outgoing nurses to sign the narcotic count sheet immediately after counting, and acknowledged that missing signatures prevent verification that counts were completed as required. The facility's policy mandates that both staff members sign the controlled substance shift change sheet to verify the accuracy of the medication counts at each shift change.
Failure to Properly Store, Label, and Cover Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's only kitchen regarding the storage, preparation, and handling of food items. Specifically, frozen French fries in the walk-in freezer were not dated, and frozen southern style biscuit dough was left uncovered in a plastic bag inside an open cardboard box. In the dry storage area, three hamburger buns wrapped in a plastic bag were found without any date or label. These observations were confirmed through interviews with the Dietary Manager, a cook, and a dietary aide, all of whom acknowledged that food items should be dated, labeled, and covered according to facility policy and professional standards. The facility's policy on food safety and the FDA Food Code require that all food items removed from their original packaging be labeled with the common name, open date, and discard date, and be stored in leak-proof, pest-proof containers with tight-fitting lids. Staff interviews revealed that responsibility for proper food storage was shared among all kitchen staff, including the Dietary Manager, cooks, and dietary aides. The staff recognized that failure to properly store food could result in food spoilage and increased risk of illness, and acknowledged that the observed deficiencies did not meet the facility's stated expectations or regulatory requirements.
Infection Control Lapses in Equipment Disinfection and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices observed among staff caring for three residents. During a morning medication pass, a medication aide did not disinfect a reusable blood pressure cuff before or after use between two residents, despite being aware of the requirement to do so. The aide admitted to forgetting this step due to nervousness and being new to the role. The Director of Nursing confirmed that staff had been trained on this expectation and that competency checks were in place. In another instance, two certified nursing assistants (CNAs) did not perform proper hand hygiene when changing gloves during morning care for a resident who was on Enhanced Barrier Precautions (EBP) due to an indwelling Foley catheter. The CNAs were observed changing gloves multiple times without sanitizing their hands, and one CNA did not wear a gown as required for EBP. Both CNAs handled the resident’s personal care, including peri-care and device care, without adhering to the facility’s infection control protocols for hand hygiene and personal protective equipment (PPE). Interviews with the involved staff revealed gaps in knowledge and adherence to infection control procedures, with one CNA stating she forgot to wear a gown and did not carry hand sanitizer, while the other was unaware of the need for a gown for residents on EBP. The facility’s policies required routine cleaning and disinfection of shared equipment, proper use of PPE, and hand hygiene before and after glove use, especially for residents on EBP. These failures were observed despite signage and supplies being available and staff having received training on infection control and EBP requirements.
Failure to Complete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to complete discharge summaries for two residents who were permanently discharged, as required by policy. For one resident, the electronic medical record (EMR) did not contain a discharge summary or a progress note indicating the resident's discharge, despite documentation that the resident was a respite admission under hospice status and was discharged to home or community. The Minimum Data Set (MDS) assessment confirmed the discharge, but the necessary summary and documentation were missing from the record. For the second resident, who had severe cognitive impairment and multiple diagnoses including diabetes, hypertension, and dementia, the nursing progress note indicated discharge with family and hospice assistance, and that medications and a comfort kit were provided. However, the EMR did not contain a discharge summary for this resident either. The MDS assessment confirmed the discharge, but the required summary was not present in the electronic chart. Interviews with facility staff, including the social worker, DON, and administrator, confirmed that the discharge summaries were not completed for these residents. The social worker, who had recently started, was unable to explain the omissions, and the DON acknowledged that the facility had been without a full-time social worker for several months. Facility policy requires an interdisciplinary discharge summary to be completed and included in the closed medical record for all permanent discharges, but this was not done for the two residents in question.
Failure to Promptly Notify Physician After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following a fall. The resident, a female with a history of repeated falls, decreased mobility, legal blindness, and other significant medical conditions, experienced a fall in the bathroom while attempting to pull up her socks. The incident was discovered by a CNA, and the resident was found on the floor with a minor bump on her head. Vital signs were taken, and the family was notified, but the physician was not promptly informed of the incident as required by facility policy. The charge nurse on duty at the time of the fall did not notify the physician until the following day, after being instructed to do so during a morning meeting. The nurse stated she was unaware of the requirement to contact the physician immediately and was not familiar with the facility's fall policy. Interviews with the DON and ADON confirmed that the facility's protocol mandates prompt physician notification after a fall, and that it was the charge nurse's responsibility to do so. Review of the facility's fall management policy corroborated this requirement.
Failure to Timely Change Oxygen Equipment for Resident on Continuous Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident requiring continuous oxygen therapy did not have their oxygen humidification bottle and nasal cannula tubing changed in a timely manner, as required by physician orders and facility policy. The resident, who had a history of stroke, hypertension, pneumonia, and diabetes mellitus, was observed with oxygen equipment that had not been changed or dated according to the weekly schedule. The humidification canister and nasal cannula tubing were last dated over two weeks prior to the observation, and the humidification bottle contained less than a quarter of water. The resident was unable to confirm how often the equipment was changed. Interviews with nursing staff and facility leadership confirmed that the expectation was for oxygen equipment to be changed and dated weekly, specifically on Sunday nights, and that this task was the responsibility of the nursing staff. The facility's policy and physician orders both required weekly changes of the oxygen equipment. Staff acknowledged that failure to change and date the equipment as scheduled could result in lapses in infection control. The deficiency was identified through observation, interviews, and record review.
Failure to Ensure Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure the privacy of a resident during medication administration. On January 1, 2025, LVN A administered insulin to a resident without closing the door or drawing the privacy curtain. This incident was captured on video footage from a Ring camera in the room, which showed the resident in a vulnerable state, wearing only a brief and uncovered from the waist down. The resident, who had a severe cognitive deficit with a BIMS score of 6, was asleep at the time of the incident. The Director of Nursing (DON) confirmed that privacy should have been provided during the administration of care. The facility's policy on patient rights emphasizes maintaining personal dignity and privacy, which was not adhered to in this instance. The DON and the Administrator both acknowledged the importance of respecting residents' privacy during care. The report indicates that the resident and their responsible party were aware of the electronic monitoring in the room and had no concerns about it. However, the failure to provide privacy during the medication administration was a clear violation of the resident's rights as outlined in the facility's policies.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated and reported to the state agency within the required five working days. An allegation of neglect was made regarding a resident who experienced a witnessed fall on the 2-10 PM shift. The resident, who had moderate cognitive impairment and was under one-to-one observation, did not sustain any injuries from the fall. However, the investigation findings were inconclusive, and the facility did not report the results to the state agency within the stipulated timeframe. The Director of Nursing (DON) and the current Administrator were aware of the incident and reported it to Texas Health and Human Services the day after it occurred. Despite this, the required Provider Investigation Report was not submitted to the state agency within five days, as required by the facility's policy. The previous administrator, who was responsible for ensuring the report was submitted, was suspended and later terminated. The facility's failure to report the findings in a timely manner placed residents at risk of not having their allegations investigated or reviewed promptly by the state survey agency.
Failure to Conduct Immediate Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. A Licensed Vocational Nurse (LVN) did not complete a fall assessment after a resident experienced a witnessed fall. The resident, who had a history of repeated falls and moderate cognitive impairment, was abruptly awakened and asked to stand and use the restroom, leading to her falling face-first on the floor. The incident occurred when the LVN, while disconnecting the resident's IV, instructed the resident to get up and go to the bathroom. The resident, who was initially asleep, was made to sit at the edge of the bed and subsequently fell forward, hitting her head on the floor. Despite the fall, the LVN did not perform an immediate assessment for injuries, vital signs, or range of motion before assisting the resident to the bathroom. The LVN's actions were captured on a Ring camera, which showed that the resident was not assessed for injuries immediately after the fall. The Dietary Aide, who was present in the room for one-on-one observation, was not trained to provide direct care and was unable to prevent the fall. The LVN failed to follow the facility's fall management protocol, which required an immediate assessment of the resident's condition post-fall. The Director of Nursing (DON) later confirmed that the LVN did not conduct a thorough assessment as required, and the LVN was subsequently suspended and terminated following the investigation.
Infection Control Breach by LVN During Medication Administration
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of LVN A while administering medications to two residents. LVN A did not perform hand hygiene or change gloves between administering insulin to one resident and discontinuing IV medication for another resident. This lapse in protocol was observed through video footage captured by a Ring camera in the residents' room, which showed LVN A entering the room with gloves already donned and failing to change them between tasks. Resident #1, a female with moderate cognitive impairment and multiple diagnoses including nontraumatic brain dysfunction and diabetes, was receiving Meropenem intravenously. Resident #2, a female with severe cognitive deficit and similar health conditions, was receiving insulin injections. The failure to change gloves and perform hand hygiene between these tasks was confirmed by both the DON and LVN A, who acknowledged the breach in infection control practices. The DON confirmed that LVN A did not follow the facility's infection control policies, which require hand hygiene and the use of new gloves for each resident interaction. LVN A admitted to being aware of these requirements but failed to adhere to them due to being in a hurry at the end of her shift. This oversight was reported by the responsible party for Resident #1, who provided video evidence to the facility and surveyors.
Failure to Ensure Accessibility of Survey Results
Penalty
Summary
The facility failed to ensure that residents, family members, and legal representatives had easy access to view the nursing home's survey results. During a confidential group meeting, residents revealed they were unaware of the location of the Federal or State survey results and their right to review them. The Activities Director was unsure of the exact location of the survey results and stated that he was responsible for informing residents of their rights during resident council meetings. The Administrator indicated that the survey results were temporarily on his desk and usually stored in a drawer in the lobby marked with a Facility Postings and Survey Results sticker. However, there was a lack of communication to residents about the location of these results. The facility's Social Services Policies and Procedures indicated that the leadership should provide a written description of the residents' legal rights, including access to state survey results. Despite this policy, the facility did not ensure that the survey results were placed in a readily accessible location or that residents were informed of their right to view these results. This oversight could lead to a lack of awareness among residents, visitors, and family members regarding the survey results and the facility's plan of correction.
Failure to Investigate Allegations of Neglect
Penalty
Summary
The facility failed to ensure all alleged violations of abuse and neglect were thoroughly investigated for two residents. Resident #370, a cognitively intact female with a history of falls, experienced an unwitnessed fall resulting in a left pelvis fracture. Despite a self-report being made regarding the fall, no investigation was conducted, and staff members were not questioned about the incident. The facility's accident report and hospital discharge report confirmed the fall and subsequent injury, but there was no documentation of an investigation being carried out by the facility's administration or nursing staff. Resident #270, a cognitively intact male requiring extensive assistance with ADLs, had an allegation of neglect reported by a family member. The family member claimed that the resident's bed was soiled with feces, prompting them to move the resident to a new facility. Although a self-report was made regarding this allegation, there was no provider incident report or documentation of an investigation. Interviews with the current DON and Facility Administrator revealed that they were unaware of any investigations being conducted for these incidents and could not locate any related documentation. The facility's policy mandates that all incidents be investigated promptly and comprehensively, with findings reported to enforcement agencies within five working days. However, the facility failed to adhere to this policy for both residents. The lack of investigation into these allegations of neglect could potentially place residents at risk for further incidents and decreased quality of care. The Corporate Executive Director confirmed that the previous Administrator may not have completed the required investigations, and no documentation was found to support that any investigations were conducted.
Failure to Implement Comprehensive Care Plan for Resident's Food Storage
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #370, who was observed keeping food in her room in unsanitary conditions. Resident #370, a cognitively intact female with multiple diagnoses including diabetes, cancer, end-stage renal disease, and dysphagia, was found with uncovered fresh produce in her room, attracting fruit flies. Despite the resident's impaired vision and preference for family-brought food, the care plan did not address the storage of fresh produce, leading to potential health risks. Interviews with staff revealed that they were aware of the issue but had not included it in the care plan, resulting in a lack of coordinated care and increased infection risk for the resident. The MDS Coordinator and DON were unaware of the extent of the issue, and the care plan had not been updated to reflect the resident's needs for sanitary food storage. Staff members, including an LVN, CNA, and MA, confirmed that the resident frequently received fresh produce from her family and stored it improperly. The facility's policy on person-centered care planning was not followed, as the care plan did not include instructions for managing the resident's food storage habits, leading to a deficiency in providing individualized care and services to meet the resident's needs.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #59, a male with dementia, muscle wasting, and cognitive communication deficit, required maximal assistance with toileting and personal hygiene. During an observation, it was noted that Resident #59 had long, discolored fingernails with dark brown residue. Interviews with staff revealed that CNAs were responsible for trimming nails of non-diabetic residents, while nurses handled diabetic residents. However, the CNA had not noticed the condition of Resident #59's nails that morning, and the DON confirmed that nail care should be completed as needed and observed daily. The facility's policy on activities of daily living indicated that necessary care should be provided to ensure residents maintain proper grooming and hygiene. Despite this policy, the staff failed to ensure Resident #59's nails were cleaned and trimmed, which could pose an infection control issue. The DON stated that routine rounds by the ADON and DON were expected to monitor such issues, but this was not effectively carried out in the case of Resident #59.
Improper Perineal Care Leading to Risk of Infection
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, CNA A did not provide proper perineal care for a resident after an incontinent episode. The CNA cleaned the resident's buttock area from back to front, which is against proper hygiene practices, and did not change gloves or perform hand hygiene when moving from dirty to clean tasks. This improper technique was acknowledged by CNA A during an interview, where she admitted to knowing the correct procedure but failing to follow it. The resident involved was a male with diagnoses including dementia, muscle wasting and atrophy, and cognitive communication deficit. His care plan indicated he required maximal assistance with toileting and personal hygiene. The Director of Nursing (DON) confirmed that the correct procedure for providing incontinent care is to clean from front to back and that failing to do so places residents at risk for infections and skin breakdown. The facility's policy on perineal and incontinent care did not address the specific concern observed.
Failure to Ensure Secure Medication Storage
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals. Specifically, the facility did not ensure that medications in unsecure containers were removed from the Med Aide Cart. During an observation and record review, it was found that a blister pack for a controlled medication used for pain had a broken seal with the pill still inside and taped over. The Med Aide responsible for the cart was unaware of when the blister pack seal was broken or who might have damaged it. The Med Aide acknowledged the risk of potential drug diversion and stated that the nurses and med aides were responsible for checking the medication blister packs during the count of narcotics at shift change, but she did not notice the broken blister during the count. The Director of Nursing (DON) stated that if a blister pack medication seal was broken, the pill should be discarded, and it would not be acceptable to keep a pill in an opened blister pack. The DON highlighted the risks of potential drug diversion and infection control issues. The facility's policy on Medication Storage indicated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures should be immediately removed from stock and disposed of according to procedures for medication destruction. The policy also stated that replacements should be reordered from the pharmacy if needed.
Infection Control Failures
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two residents. For Resident #59, a CNA did not perform hand hygiene or change gloves during incontinence care. The CNA used the same gloves to remove a soiled brief and place a clean one, and did not clean from front to back as required. The CNA acknowledged the failure to follow proper procedures, which exposed the resident to potential infections. For Resident #46, an LVN did not perform hand hygiene after conducting a finger stick blood sugar (FSBS) test and cleaning the glucometer. The LVN used the same gloves to handle the medication cart and administer insulin without sanitizing hands in between. The LVN admitted to realizing the mistake and acknowledged the risk of cross-contamination and infection. The Director of Nursing confirmed that staff are expected to sanitize their hands when transitioning from dirty to clean tasks.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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