Cypress Creek Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cypress, Texas.
- Location
- 13600 Birdcall Lane, Cypress, Texas 77429
- CMS Provider Number
- 676467
- Inspections on file
- 32
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Cypress Creek Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, CKD, and a UTI received IV Vancomycin ordered every 12 hours with instructions for a trough level to be drawn after the 4th dose for ongoing monitoring. The MAR showed that the 4th and multiple subsequent Vancomycin doses were administered without a documented trough level, while nursing notes indicated the antibiotic was continued and the order for the trough was being clarified. The DON later reported that the trough order had been incorrectly set to start several days later, resulting in doses being given before a level was known. When a stat trough was finally drawn, the Vancomycin level was critically high, and the on-call physician was notified and ordered doses to be held, demonstrating a failure to follow MD orders and facility policy for IV medication monitoring.
A resident with cerebral palsy, depressive and mood disorders, and intellectual disabilities, but intact cognition per BIMS, had her electronic medical record left open and unattended on a medication cart, displaying her room, DOB, allergies, code status, and medications. A respiratory therapist reported she left the record open while quickly administering an inhaler and acknowledged that anyone could view the information. The DON stated records should be locked when staff walk away and that leaving them open is a HIPAA violation, while the administrator noted the EMR has a timeout and can be minimized. The facility’s resident rights policy affirms residents’ rights to privacy and to secure, confidential personal and medical records.
A resident with multiple diagnoses, including dry eye syndrome and dementia, developed new redness and drainage in one eye, leading the MD to order Azithromycin ophthalmic drops twice daily. The MAR reflected the new order, but the comprehensive care plan was not revised to include this change in condition or related interventions. Interviews with the DON, ADON, MDS nurse, and administration confirmed that facility policy and practice require immediate or within-24-hour care plan updates after a status change, yet this did not occur for the resident’s eye condition.
Surveyors found two unlocked medication carts during med pass, one used by a respiratory therapist on one hall and another by an LVN on a different hall. The respiratory therapist reported she forgot to lock the cart while assisting a resident with medications, and the LVN reported she left her cart unlocked when responding to a resident yelling for help. The facility’s policy requires all drugs and biologicals to be stored in locked compartments and that medications be either under direct observation during pass or locked, and leadership acknowledged that unlocked carts create a risk of medication being taken and potential harm to residents.
A resident with severe cognitive impairment was physically abused by a CNA, who slapped her on the cheek and acted aggressively. In a separate incident, another resident with dementia and behavioral disturbances struck the same resident multiple times in the arm. Both incidents were witnessed and confirmed, and the affected resident was dependent on staff for care. The facility's existing care plans and interventions did not prevent these abusive events, and some residents were unaware of their rights or how to report abuse.
The facility failed to immediately report allegations of abuse and significant injuries of unknown origin for two residents, including a resident with severe cognitive impairment who sustained unexplained bruising and a fractured arm, and another resident who was slapped by a CNA. In both cases, required notifications to the administrator and state agency were delayed beyond the mandated two-hour window, with staff interviews revealing confusion about reporting procedures and documentation showing lapses in timely communication.
A resident with cognitive and behavioral challenges was subjected to verbal abuse by a CNA, who responded to the resident's use of a racial slur with racially charged and threatening remarks, intimidation, and inappropriate conduct. The incident, captured on video and witnessed by staff and family, demonstrated a failure to follow the resident's care plan and facility policies prohibiting abuse.
Failure to Monitor Vancomycin Trough Levels Before Continued Dosing
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate monitoring and administration of IV Vancomycin for one resident. The resident was an elderly female with dementia, urinary tract infection, chronic kidney disease, acute kidney failure, and hypertension, who was dependent on staff for ADLs and had moderately impaired cognitive skills. Physician orders dated 12/3/25 directed Vancomycin 1 g IV every 12 hours for 14 days for a UTI, with a Vancomycin trough to be drawn at 6 a.m. after the 4th dose every 7 days for two weeks. The Medication Administration Record showed Vancomycin doses given at 7:00 a.m. and 7:00 p.m. starting on 12/3/25, with the 4th dose administered on 12/5/25 at 7:00 a.m., but there was no documentation that a Vancomycin trough was collected after this 4th dose as ordered. Despite the absence of a documented trough level after the 4th dose, Vancomycin continued to be administered on multiple subsequent shifts. Nursing notes documented that the resident continued on IV Vancomycin with no adverse effects noted and that the IV site was intact and flushing well. A late entry nursing note indicated that an LVN was clarifying the Vancomycin trough order, but the MAR still showed that the LVN had administered a dose on the morning in question. Another nurse later documented that the resident received a dose of Vancomycin on her shift and tolerated it well. The DON later stated that a nurse had entered the Vancomycin trough order to start on 12/7/25 instead of after the 4th dose, and that some Vancomycin doses were given before the trough level was known. On 12/7/25, an RN documented that no Vancomycin level had been obtained despite the resident having received more than four doses, and contacted the lab for a stat trough before the next dose. A Vancomycin trough was collected that afternoon, and the laboratory result showed a critical high level of 33.7 ug/mL (reference range 10.0–20.0), which was called into the facility that night. A nursing note documented that this critical trough level was reported to the on-call physician, who ordered the next two doses of Vancomycin to be held. The resident’s physician later stated that Vancomycin troughs were normally drawn 30 minutes to 1 hour before every 4th dose and that without knowing the initial trough, nursing staff could not continue to give the medication. The facility’s policies on medication administration and IV therapy required medications to be administered as ordered by the physician and in accordance with professional standards of practice, including review and verification of orders for dose and frequency, which did not occur in this case.
Failure to Maintain Confidentiality of Resident Electronic Medical Record
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident’s personal and medical records when the resident’s electronic medical record (EMR) was left open and unattended on a medication cart. The resident was an adult female with cerebral palsy, major depressive disorder, mood disorder due to a known physiological condition, and intellectual disabilities, with an initial admission date in 2022 and a recent readmission. A Quarterly MDS assessment documented a BIMS score of 15, indicating intact cognition with normal memory and recall. Her care plan noted a risk for cognitive impairment related to mild intellectual disorders, with interventions to monitor and report changes in cognitive function. Despite this, during an observation on the 100 hall, her EMR was visible on the cart screen, displaying her room location, date of birth, allergies, code status, and medications. During an interview shortly after the observation, the respiratory therapist who had been administering an inhaler to the resident acknowledged leaving the medical record open and unattended, explaining she was trying to quickly administer medication and did not realize the record remained open. She stated that leaving medical records open allowed anyone to view the documents. The DON stated that medical records should not be left open when staff walk away from the cart and should be locked, noting that wandering eyes could view residents’ information and that this constituted a HIPAA violation. The administrator reported that the EMR has a built-in timeout and that staff can minimize the screen to lock it before walking away, and also noted that in-services on confidentiality are conducted periodically. The facility’s Resident Rights policy, revised in 01/2025, states that residents have the right to personal privacy and to secure and confidential personal and medical records, and the right to refuse release of such records except as allowed by law.
Failure to Revise Care Plan After Resident Eye Condition Change
Penalty
Summary
The facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after a documented change in condition for one resident. The resident was an older male with an initial admission in early April 2023 and a recent readmission, with diagnoses including dry eye syndrome, cerebral infarction, dementia, congestive heart failure, dizziness and giddiness, and chronic cough. An MDS assessment showed a BIMS score of 13 and indicated the resident could see fine detail such as regular print. A change in condition progress note dated 01/27/2026 documented that the resident developed redness to the right eye with a small amount of drainage, and the physician ordered Azithromycin 1% ophthalmic solution, one drop to the right eye twice daily for five days. The Medication Administration Record reflected this new order dated 01/27/2026. Despite this documented change in condition and new treatment order, review of the resident’s care plan showed no indication of a change in condition regarding the eye. Interviews with the DON, Administrator, MDS Specialist (LVN), and ADON confirmed that the facility’s expectation and policy were that care plans be updated immediately or within 24 hours after a status change, typically following SBAR completion and IDT discussion, and that such updates are then communicated to staff via the Kardex. The DON acknowledged that for this resident the care plan was not updated timely and accepted accountability. Staff interviews consistently identified that the care plan should have been revised after the change in condition was identified and the new order was received, but this did not occur for the resident’s right eye redness and drainage.
Unlocked Medication Carts During Med Pass
Penalty
Summary
Surveyors identified a deficiency related to medication storage and security when two medication carts were found unlocked during observations. On the 100 hall, the respiratory therapist’s medication cart was observed unlocked at 7:18 a.m. The respiratory therapist stated in an interview that she had been assisting a resident with medications and forgot to lock the cart, acknowledging that anyone could come and take the medications. The facility’s Medication Storage policy, revised 05/2023, requires that all drugs and biologicals be stored in locked compartments and that, during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area or cart. On the 300 hall, a nurse’s medication cart was observed unlocked at 7:24 a.m. The LVN assigned to that cart stated in an interview that she heard a resident yelling for help and went to assist, leaving the cart unlocked. She stated that the risk of leaving the cart unlocked was that a resident could possibly get into the cart and take medication. In interviews, the DON stated that the expectation is for medication carts to be locked before staff walk away, and the risk of unlocked carts is that medication could be taken out and used for alternative purposes. The administrator stated that, for safety and security, they conduct purposeful rounding to double-check that medication carts are locked when staff walk away and that her role is to ensure systems are completed within local and state compliance and to address deficient practices. The report notes that the risk of medication carts being unlocked is medication error and potential harm to residents.
Failure to Prevent Staff and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by a staff member and another resident. One incident involved a CNA physically abusing a resident with severe cognitive impairment by slapping her on the left cheek with an open hand and pointing at her aggressively. The resident, who had diagnoses including colon cancer, hemiplegia, vascular dementia, and adjustment disorder, was dependent on staff for activities of daily living and had a BIMS score indicating severe cognitive impairment. The abuse was confirmed through video evidence and staff interviews, with the CNA admitting to the act during an interview. The incident was reported by another CNA, and the resident was observed to be yelling and distressed immediately after the event. A second incident involved resident-to-resident abuse, where another resident with severe cognitive impairment and a history of behavioral disturbances struck the same resident three times in the arm with a closed fist. This altercation occurred at the nurse's station and was witnessed by an LVN. The aggressor resident had a history of dementia with behavioral disturbance, diabetes, and other significant medical conditions. The behavior was noted to be outside her baseline, and it was later determined that she had a urinary tract infection and elevated ammonia levels, which may have contributed to the aggression. Both residents were assessed after the incident, and no visible injuries were noted. The facility's care plans for both residents included interventions for managing unwanted behaviors and cognitive impairment, but these interventions did not prevent the incidents of abuse. Staff interviews indicated that some residents were unaware of their rights or how to report abuse prior to the incidents. The events placed residents at risk of abuse and mental anguish caused by fear, as directly observed and documented by surveyors.
Failure to Timely Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source and misappropriation of resident property—were reported immediately, but not later than two hours after the allegation was made, to the administrator and to other officials, including the State Survey Agency, as required by state law. This deficiency was identified for two residents reviewed for abuse and neglect. In one case, a resident with severe cognitive impairment and multiple comorbidities, including dementia and diabetes, was found to have scattered bruising of different colors and a fractured arm. The injury was not reported to the state agency or the abuse coordinator in a timely manner, despite the presence of significant bruising and a fracture of unknown origin. Staff interviews revealed confusion about the timing and reporting of the injury, with some staff believing the injury was older than it appeared and others unsure of who had been notified. Documentation showed that the injury was not immediately recognized or reported, and the cause of the injury remained unclear. In another instance, an allegation of abuse involving a staff member slapping a resident on the cheek was not reported to the administrator or the state agency within the required two-hour timeframe. The incident was reported 15 hours after it occurred. Staff interviews indicated a lack of clarity regarding the appropriate method and urgency of reporting such incidents, with some staff relying on text messages rather than direct phone calls to notify management. The facility's own policy required immediate reporting of suspected abuse, neglect, or injury of unknown origin, but this was not followed in practice. Both failures were substantiated by record reviews, staff interviews, and review of facility policies. The lack of timely reporting of these incidents could place residents at risk for abuse or neglect and could lead to a diminished quality of life, as stated in the report. The findings highlight lapses in communication, documentation, and adherence to established procedures for reporting suspected abuse and significant injuries.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) engaged in verbally abusive behavior toward a male resident with a history of psychotic and mood disturbances, anxiety, dementia, and other medical conditions. The incident began when the resident, who was cognitively intact according to his most recent assessment, used a racial slur toward the CNA. In response, the CNA pointed her finger close to the resident's face, made racially charged and derogatory remarks, threatened to remove the resident's refrigerator, and turned off the lights in the resident's room, telling him to "stay in the dark." The interaction was captured on a camera in the resident's room, and the resident's family was alerted to the commotion via a motion notification from the camera. The resident's care plan documented his communication difficulties, occasional resistance to care, and a history of unwanted behaviors, including aggression and use of inappropriate language. Despite these challenges, the care plan included interventions such as using simple language, allowing time for responses, and providing choices during care. On the day of the incident, the CNA did not follow these interventions and instead escalated the situation by responding to the resident's verbal aggression with her own verbal abuse and intimidation. The incident was witnessed by another CNA, who confirmed the resident's use of a racial slur but did not recall threatening or disrespectful language from the CNA involved, although video evidence and interviews contradicted this account. Following the incident, the resident was assessed and found to have no physical injuries or signs of emotional distress, and he later reported that while the CNA's behavior did not make him sad or angry, he did not feel good about the interaction. The CNA involved refused to provide a statement and left the facility, effectively self-terminating her employment. The facility's policies on resident rights and abuse prohibit such behavior, defining verbal abuse as the use of disparaging or derogatory terms within a resident's hearing, regardless of their ability to comprehend. The actions of the CNA were found to be in violation of these policies, constituting a failure to protect the resident from abuse.
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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