Cypress Springs Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Texas.
- Location
- 501 Yates Street, Mount Vernon, Texas 75457
- CMS Provider Number
- 676477
- Inspections on file
- 21
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Cypress Springs Wellness & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to follow its policy requiring daily temperature monitoring and documentation for residents’ personal in-room refrigerators and freezers used to store food brought by families and visitors. Several residents with multiple chronic conditions and varying cognitive status had personal refrigerators containing perishable items such as milk and ice cream, but temperature logs showed entries on only some days, with gaps where no temperatures were recorded. Although observed temperatures were within acceptable ranges at the time of survey, logs for multiple refrigerators were incomplete, and staff interviews revealed confusion over which department was responsible for daily temperature checks and that existing rounding tools did not instruct staff to verify refrigerator and freezer temperatures as required by policy.
A resident receiving scheduled nebulizer treatments for acute respiratory failure with hypoxia had a nebulizer mask and tubing left on a recliner rather than stored in a protective, labeled, and dated bag as required. Staff interviews revealed uncertainty about who was responsible for proper storage and when nebulizer equipment should be changed. The DON and Administrator indicated that equipment should be stored in a clean, dated bag with routine change orders, and facility policy required weekly changes and bedside bag storage for oxygen-related equipment, which was not followed.
Surveyors observed an open can of an energy drink stored in the kitchen walk-in cooler alongside residents’ food, despite facility policy prohibiting personal belongings in food preparation or storage areas. The FSS reported that staff had been previously in-serviced that personal drinks were not allowed near residents’ food due to infection control, and a dietary staff member admitted the drink was hers and that she knew it should not have been in the cooler. The Administrator confirmed that personal food and drink items are not permitted near food preparation or storage areas and that the FSS is responsible for preventing this practice.
The facility did not obtain ordered laboratory tests for three residents, including missed CMP, CBC, and urinalysis collections, despite physician orders and care plan requirements. Staff interviews revealed confusion about active lab orders after a change in medical directors and inconsistent communication and follow-up regarding outstanding lab collections.
A resident with a seizure disorder had a lab result showing an elevated Keppra level, which was above the therapeutic range. The medical director questioned the current Keppra dosage, but nursing staff did not respond or document any follow-up. The resident continued to receive the medication as ordered, and the facility's required process for addressing high medication levels was not followed.
A resident with hemiplegia and dementia did not have a comprehensive admission MDS assessment completed within the required 14-day timeframe. The assessment was signed 8 days late due to coordination issues between the MDS Coordinator, who was not an RN and worked at multiple sites, and the DON, who was unaware of the required deadlines and unable to sign assessments daily.
Surveyors identified that two residents did not have complete, up-to-date care plans reflecting their assessed needs. One resident's care plan required a fall mat to be in place while in bed, but observations showed the mat was not used as directed, and there was no documentation explaining its absence. Another resident was prescribed an antidepressant, but this was not included in the care plan, contrary to facility policy. These omissions were confirmed by staff interviews and record reviews.
A resident with moderate cognitive impairment and multiple medical conditions was found to have a bottle of meyer's cleaner left on his bedside table, brought in by a family member. Staff and administration acknowledged that hazardous items should not be present in resident rooms, but the facility lacked a policy addressing this issue. The cleaner remained in the room over multiple days, and staff did not remove it, creating a risk for injury.
Two residents were found with medications and biologicals left unsecured at their bedsides, including wound cleanser, non-prescribed powder, and artificial tears, despite facility policy requiring locked storage and staff administration. Neither resident had been assessed for self-administration, and staff were unclear about authorization, resulting in medications being accessible in resident rooms.
The facility did not obtain or maintain the most recent hospice plan of care and nursing visit notes for a resident with multiple medical conditions receiving hospice services. Required hospice documentation was not delivered to the facility as expected, resulting in outdated records and a lack of coordination between facility staff and hospice representatives.
Two residents did not receive care in accordance with infection control protocols: a nurse failed to wear required PPE during wound care for a resident with a Foley catheter, and a CNA did not perform hand hygiene between glove changes during incontinent care for another resident. Both staff members acknowledged the lapses, and facility leadership confirmed these actions were not consistent with policy.
A resident alleged rough handling and verbal mistreatment by a CNA during care, which was witnessed by another CNA who did not report the incident promptly. The DON and ADON were notified of the allegation via text but did not inform the abuse coordinator, allowing the alleged perpetrator to continue working. Additionally, several CNAs had not received required abuse training before providing care, as confirmed by personnel records and staff interviews.
A resident with rheumatoid arthritis and PTSD, who was cognitively intact and dependent on staff for care, experienced disrespectful treatment from CNAs. One CNA provided care while wearing earbuds and was inattentive, while another spoke to the resident in a disrespectful manner, making the resident feel awful. Witness statements and staff interviews confirmed these actions, which violated facility policy and resident rights.
The facility failed to maintain food safety standards as Cook K used malfunctioning thermometers to check food temperatures, and the Maintenance Supervisor entered the kitchen without performing hand hygiene or wearing a hair restraint. Despite reheating, food temperatures remained inconsistent, posing a risk of foodborne illness.
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies. Staff did not perform hand hygiene or change gloves during care, did not clean equipment between uses, and were unaware of a resident's contact isolation precautions, placing residents at risk for infection.
The facility failed to assist a resident with severe cognitive impairment in removing facial hair, despite the resident being dependent on staff for all ADLs. Staff interviews and observations confirmed that the resident did not refuse care, and it was the responsibility of CNAs and nurses to ensure grooming was completed during bathing.
The facility failed to ensure that a medication cart was locked and secure, posing a risk of unauthorized access to medications. An unlocked cart was found in the hallway near the dining room, with multiple residents around. Staff interviews confirmed that medication carts should always be locked when unattended, as per facility policy.
Failure to Perform Daily Temperature Monitoring of Residents’ Personal Refrigerators
Penalty
Summary
The deficiency involves the facility’s failure to implement its policy for monitoring and documenting temperatures of residents’ personal in-room refrigerators and freezers used to store food and beverages brought in by families and visitors. The written policy, dated 01/01/2025, required that a temperature monitoring log be maintained, that a designated staff member document refrigerator temperatures daily, and that a thermometer be kept in the refrigerator to maintain a temperature of 41 degrees or below. Surveyors found that temperature checks were not being performed and documented daily as required, despite residents having personal refrigerators containing perishable items. For one resident with COPD, deep vein thrombosis, schizophrenia, and depression, who had intact cognition with a BIMS score of 13, observation showed a personal refrigerator containing a gallon of milk with a valid expiration date. The temperature log taped to the side of the refrigerator showed entries only on four dates, rather than daily, and all recorded temperatures were 32 degrees. The thermometer inside the unit read 32 degrees in the refrigerator and 22 degrees in the freezer at the time of observation, which were within acceptable parameters, but the monitoring was not done every day. The resident stated he did not know who checked the thermometer and did not recall having spoiled food. For another resident with cervical disc degeneration, cerebral infarction, aphasia, hypertension, and chronic kidney disease, and a BIMS score of 3 indicating severe cognitive impairment, observation revealed a personal refrigerator with three pints of ice cream in the freezer, all with future expiration dates. The temperature log showed checks on only three dates, with refrigerator and freezer temperatures within acceptable ranges, but again not documented daily. A third resident with diabetes type II, unspecified chronic bronchitis, and spinal cord disease, and intact cognition with a BIMS score of 15, had a personal refrigerator log with missing temperature entries for two consecutive days, indicating temperatures were not obtained daily. This resident reported that staff did not always keep up with temperature checks, though they looked at the refrigerator daily. Interviews with the DON, Housekeeping Supervisor, and Administrator confirmed that nursing staff were not responsible for monitoring these temperatures, that housekeeping had not been clearly informed of this responsibility until after the survey date, and that the Ambassador Round sheet used by staff did not direct them to check refrigerator and freezer temperatures, resulting in the failure to carry out the facility’s policy.
Improper Storage and Lack of Dating for Nebulizer Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards of practice for a male resident with intracerebral hemorrhage, hypertension, hyperlipidemia, and dysphagia. The resident had a physician’s order for Ipratropium-Albuterol inhalation solution via nebulizer three times daily for acute respiratory failure with hypoxia, and the MAR showed the treatment was administered as ordered. During observation, the resident’s nebulizer mask and tubing were found lying on a recliner chair in his room, not stored in a protective bag. Although a storage bag was present, it was neither labeled nor dated, and there was no physician’s order specifying when to change or date the nebulizer mask and tubing. In interviews, an RN reported being unsure who was responsible for ensuring nebulizer masks were properly stored, labeled, and dated, and stated she did not know when the nebulizer equipment should be changed. The DON stated that nebulizer masks and tubing should be stored in a clean bag, with both the equipment and bag dated, and that the tubing and mask were typically changed on Sundays with an order in place for routine changes. The Administrator stated that nursing staff were responsible for ensuring nebulizer equipment and oxygen tubing were properly stored in a bag with a date and that each resident should have an order addressing respiratory supply changes. The facility’s Oxygen Administration policy required that oxygen tubing, humidifiers, masks, and cannulas be changed weekly and when visibly soiled, and stored in a plastic bag at the bedside when not in use, which was not followed in this case.
Personal Beverage Stored in Walk-In Cooler with Residents’ Food
Penalty
Summary
Surveyors identified a deficiency in food storage practices when, during observation of the kitchen’s walk-in cooler, they found an open 16-ounce can of an energy drink that was more than two-thirds full stored inside with residents’ food items. The Food Service Supervisor (FSS) acknowledged during interview that staff had been in-serviced that personal drinks were not allowed in kitchen areas near residents’ food items due to infection control. A dietary staff member admitted the drink belonged to her, stated she knew she was not supposed to have the open drink in the walk-in cooler, and acknowledged that this practice could result in contamination. The Administrator confirmed that no personal food or drink items should be near food preparation or storage areas due to risk of contamination and stated that the FSS was responsible for ensuring this practice did not occur. Review of the facility’s “Nutrition Services Personnel Guidelines” policy, dated 01/01/2026, showed that all personal belongings may not be kept in food preparation or food storage areas. This deficiency reflects the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards and its own policy by allowing personal beverages to be kept in the walk-in cooler used for residents’ food.
Failure to Obtain Ordered Laboratory Services for Multiple Residents
Penalty
Summary
The facility failed to ensure that laboratory services were obtained as ordered for three residents. One resident with diagnoses including cerebrovascular disease, hypertension, hypothyroidism, and prediabetes had a physician's order for a Comprehensive Metabolic Panel (CMP) on admission and every three months, but the last CMP was collected several months prior to the review, and there was no care plan addressing lab collection. Another resident with Parkinson's disease, hyperlipidemia, and chronic kidney disease had orders for a CBC and CMP every three months, but these labs were also not collected as ordered, with the last collection occurring months earlier. The care plan for this resident did mention monitoring labs, but the orders were not followed. A third resident, admitted with Parkinson's disease and benign prostatic hyperplasia, had an order for a urinalysis upon admission. Documentation showed repeated notations over several days that the urinalysis was needed, but the specimen was not collected until more than a week after the order. Nursing staff interviews revealed that attempts to collect the specimen were unsuccessful, and alternative collection methods were not pursued. Communication about the outstanding lab order was inconsistent, and the need for the urinalysis was not consistently documented in the 24-hour report. Interviews with nursing leadership indicated confusion regarding lab order discontinuation following a change in medical directors, with some staff believing the orders were no longer active. Leadership also acknowledged that lab collection should have been monitored and communicated more effectively among staff. The facility's policy required the team to process and arrange for lab tests as ordered by the physician, but this was not consistently followed for the residents in question.
Failure to Notify Physician and Follow Up on Elevated Keppra Level
Penalty
Summary
The facility failed to promptly notify and follow up with the ordering physician regarding a laboratory result that was outside the clinical reference range for one resident. The resident, an elderly female with a history of cerebrovascular disease, seizures, and dementia, had a physician's order for a Keppra level to be drawn and monitored. The lab result, received and electronically signed by the medical director, showed a Keppra level above the therapeutic range. The medical director specifically questioned the resident's current Keppra dosage in response to the elevated result. Despite the physician's inquiry, there was no documented response from the nursing staff regarding the resident's current Keppra dose. Review of the facility's 24-hour reports and progress notes revealed no indication that the lab result was addressed or that the physician's question was answered. The resident continued to receive her prescribed Keppra dosage, and there was no documentation of any changes to her medication or further follow-up regarding the elevated lab value. Interviews with the DON and nursing staff confirmed that the elevated Keppra level and the physician's inquiry were not followed up on or documented. The DON acknowledged that the lab result was not written on the 24-hour report for follow-up and that the process for addressing such results was not completed. The facility's policy required prompt physician notification and withholding of the next dose in the event of a high or toxic medication level, but this procedure was not followed in this instance.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within 14 calendar days after admission, as required. Specifically, the admission Minimum Data Set (MDS) assessment for a female resident with hemiplegia, hemiparesis following a stroke, and dementia was not completed on time. The resident was admitted on 03/04/2025, but the MDS assessment, which had an Assessment Reference Date (ARD) of 03/11/2025, was not signed as completed until 03/25/2025, making it 8 days late. Interviews with facility staff revealed that the MDS Coordinator, who was not an RN and worked at two different buildings, relied on the DON to sign off on MDS assessments. The MDS Coordinator attempted to notify the DON via email about assessments needing signatures, but the DON was not always able to check or sign them daily due to other responsibilities and was unaware of the required timeframes. The Administrator expected timely completion but was not aware of the clinical implications. Facility policy required a registered nurse to coordinate and sign each assessment within the specified timeframes, which was not followed in this instance.
Failure to Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through observation, interviews, and record reviews. For one resident, who had diagnoses including dementia, chronic kidney disease, anxiety, and hypertension, the care plan required a fall mat to be in place while the resident was in bed due to a recent fall. However, during multiple observations, the fall mat was found folded and not in use while the resident was in bed. Staff interviews revealed that the resident had previously moved the mat herself and sometimes requested its removal, but there was no documentation explaining why the intervention was not in place as required by the care plan. For another resident with diagnoses of dementia, urinary retention, heart failure, and hypertension, the care plan did not include the use of an antidepressant medication, despite the resident having an active order for citalopram for depression. The resident's medication administration record confirmed ongoing use of the antidepressant, but this was not reflected in the care plan. Interviews with the DON and Administrator confirmed that the care plan should have included this medication and the associated diagnosis. The facility's policy requires that care plans be comprehensive, person-centered, and updated to reflect all relevant diagnoses, medications, and interventions based on ongoing assessments. The failures identified in these two cases resulted in care plans that did not accurately reflect the residents' needs or the interventions required to address those needs, as evidenced by the lack of a fall mat in use and the omission of an antidepressant medication from the care plan.
Failure to Remove Hazardous Cleaner from Resident Room
Penalty
Summary
A deficiency occurred when a resident's environment was not kept free from accident hazards, as evidenced by a blue bottle of meyer's cleaner being left on the bedside table in the resident's room. The resident, a male with diagnoses including heart failure, diabetes, glaucoma, kidney failure, anxiety, and high blood pressure, had moderate cognitive impairment and required total assistance with most activities of daily living. Observations on two separate days confirmed the presence of the cleaner in the room. Staff interviews revealed that the cleaner had been brought in by a family member, and both the RN and DON acknowledged that such items should not be present in resident rooms due to the risk of ingestion by the resident or others. Further review showed that the facility did not have a policy addressing hazardous items or the storage of cleaners in resident areas. The administrator confirmed that staff were expected to ensure hazardous items were not left in resident rooms, but acknowledged that there was no formal policy in place. The lack of staff action to remove the cleaner and the absence of a relevant policy contributed to the deficiency, placing residents at risk for injury.
Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and only accessible to authorized personnel, as required by policy. For one resident with moderate cognitive impairment and multiple diagnoses, including heart failure and diabetes, a bottle of wound cleanser and a container of non-prescribed buttocks powder were observed left on the bedside dresser on multiple occasions. The resident's care plan required staff to administer medications as prescribed, and there was no order for the buttocks powder. Despite previous discussions with the resident's family, these items remained accessible at the bedside. Another resident, who was cognitively intact and at risk for substance abuse, was found with artificial tears on his bedside table. There was no physician order for these eye drops, and the resident reported self-administering them as needed. Nursing staff were unsure if this resident was authorized to self-administer medications, and the DON confirmed that neither resident had been assessed for self-administration. Facility policy required that only authorized staff have access to medications, and that medications be stored in locked areas, but these procedures were not followed for the two residents.
Failure to Maintain Updated Hospice Documentation and Coordination
Penalty
Summary
The facility failed to collaborate and coordinate with hospice representatives to ensure the hospice care planning process was properly managed for a resident receiving hospice services. Specifically, the facility did not obtain the most recent updated hospice plan of care and hospice nursing visit notes for a female resident with a history of cerebrovascular disease, seizures, and dementia. The resident was moderately cognitively impaired and was receiving hospice care as indicated in her care plan and medical orders. However, the hospice binder at the facility only contained outdated documents, with the most recent RN visit note and hospice plan of care update both over a month old. Interviews with the Hospice Director of Nursing (DON), facility DON, and Administrator revealed that hospice documents were expected to be delivered to the facility every two weeks following the hospice interdisciplinary team (IDT) meeting. Due to the absence of the hospice Assistant Office Manager, the updated documents had not been delivered as required, and the responsible staff had not realized the lapse. The facility's contract with the hospice provider required the provision of the most recent hospice plan of care and clinical notes after each visit, but these were not present in the resident's records at the time of the survey.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents during direct care activities. For one resident with a history of heart failure, diabetes, kidney failure, and other chronic conditions, who had a Foley catheter and required wound care, a registered nurse provided wound care without donning an isolation gown as required by the facility's enhanced barrier precautions policy. The nurse acknowledged during an interview that she should have worn a gown and gloves prior to providing care, and that the resident required enhanced barrier precautions for both catheter and wound care. In a separate incident, a certified nursing assistant provided incontinent care to another resident with a history of cerebrovascular disease, seizures, and dementia, who was dependent on staff for all activities of daily living and was always incontinent of urine and bowel. During the care process, the CNA failed to perform hand hygiene after removing soiled gloves and before applying clean gloves. The CNA admitted to forgetting to sanitize her hands between glove changes, which she recognized as a lapse in proper infection control practice. Interviews with the Director of Nursing and the Administrator confirmed that staff are expected to use appropriate personal protective equipment and perform hand hygiene according to facility policy. Both acknowledged that failure to follow these protocols could place residents and staff at risk for infection, and that the individuals providing care are responsible for adhering to infection control procedures.
Failure to Prevent and Report Resident Abuse Due to Policy and Training Lapses
Penalty
Summary
The facility failed to implement and enforce written policies and procedures to prohibit and prevent abuse and neglect of residents, as evidenced by an incident involving a resident who alleged that a CNA was rough during incontinent care, pushing her left shoulder and nearly causing her to hit her head on the bed rail. Another CNA witnessed the alleged abuse but did not report it promptly to the abuse coordinator, citing discomfort and fear of repercussions as a new employee. The incident was instead relayed to another CNA during shift report, who then sent a text message to the DON and ADON, but the abuse coordinator was not notified until much later by the surveyor. The DON and ADON did not immediately notify the abuse coordinator upon receiving the allegation of abuse via text message. Both later stated they did not recall receiving or responding to the message until it was brought to their attention by the surveyor. As a result, the alleged perpetrator was allowed to continue working their shift and provide care to residents after the allegation was made. The administrator confirmed that if he had been notified in a timely manner, the CNA in question would not have worked the subsequent shift. Additionally, the facility failed to ensure that CNAs received abuse training upon hire and prior to providing care. Personnel files revealed that several CNAs did not complete abuse training until weeks or months after their hire dates. The business office manager acknowledged delays in training completion and stated there was no specific policy regarding the timing of abuse training. These failures were identified during interviews and record reviews, and the lack of timely reporting and training placed residents at risk of unreported abuse and neglect.
Removal Plan
- ADON, MDS coordinator and Administrator will conduct 100% resident rounds to determine if further allegations of abuse are alleged.
- Safe surveys will be conducted by Social Worker, Human Resources and Activity Director for all cognitive residents.
- C.N.A. A was educated on Abuse, neglect and reporting by DON.
- C.N.A. B and D were suspended and terminated.
- DON and ADON were given a final written warning stating any further failures would result in termination and were re-educated by Administrator.
- The Abuse Coordinator was educated by the Regional Director of Clinical Services on how to investigate allegations of abuse, reporting of abuse and the importance of a thorough investigation and written documentation of statements and in-services.
- In-servicing was initiated by Administrator on Abuse investigation, notification, and immediate removal of the perpetrator for the DON and ADON.
- In-service will be provided to all staff on Immediate Notification of Allegations to Facility Abuse Coordinator or designee when not in facility or available, Investigating Allegations of Abuse and Neglect, Reporting of Abuse Neglect and Misappropriation, and notification of proper local and state entities by DON and ADON.
- Agency staff that work in the facility or staff on PTO or LOA will have in-servicing completed prior to working the floor by the DON/ADON.
- Abuse and Neglect training will be a part of the new hire orientation and no staff will be allowed to work until the Administrator has verified that training has occurred. This training will include all aspects of Reporting Abuse, Investigating Abuse and resident protection from abuse and will be completed at time of hire by HR/DON and verified by Administrator.
- Any staff member who is an alleged perpetrator for any allegation will be suspended immediately pending investigation and will be escorted out of the facility immediately by the senior staff member on duty or law enforcement and will not be allowed to return to the building until the investigation is complete.
- The police were notified of the allegation of abuse by the Administrator.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
The facility failed to ensure that staff treated a resident with respect and dignity, as required by resident rights regulations. One incident involved a CNA providing care to a resident while wearing earbuds, which was confirmed by a witness statement and staff interview. The CNA was reportedly inattentive and did not engage with the resident during care, which was identified as a respect issue by both the witness and the Director of Nursing (DON). Facility policy and staff expectations prohibit the use of earbuds or cell phones during resident care, and random spot checks are conducted to monitor compliance. Another incident involved a different CNA speaking to the same resident in a disrespectful manner. According to a witness statement and staff interviews, the CNA told the resident she would no longer be friendly because the resident was allegedly trying to get staff in trouble. This interaction made the resident feel awful, as reported during an interview. The DON and Administrator both acknowledged that such behavior constitutes a failure to treat residents with respect and dignity, and emphasized the importance of staff treating residents as they would their own family members. The resident involved had a history of rheumatoid arthritis and PTSD, with intact cognition and dependence on staff for various activities of daily living. The care plan noted a history of the resident making complaints about staff, and interventions included having two staff present during care when possible. Despite these measures, the facility did not prevent the incidents of disrespectful behavior and inattentive care, as documented in staff and resident interviews and witness statements.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Cook K was observed using three different thermometers to check the temperatures of the lunch meal on the steam table, but none of the thermometers provided consistent readings. Despite reheating the food, the temperatures remained inconsistent, with some items like pureed steak fingers and gravy not reaching the required temperature of 135 degrees Fahrenheit. The Dietary Manager (DM) instructed Cook K to serve the food, believing it was at the correct temperature, although the thermometers were not functioning properly. Additionally, the Maintenance Supervisor entered the kitchen to get ice without performing hand hygiene or wearing a hair restraint. The Maintenance Supervisor admitted to being unaware of the need for these precautions but acknowledged the potential for cross-contamination after considering the situation. The DM confirmed that the Maintenance Supervisor should have asked for ice from the kitchen staff and should have performed hand hygiene and worn a hair restraint before entering the kitchen area. Interviews with the Dietician, Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator revealed that they were aware of the importance of maintaining proper food temperatures, hand hygiene, and wearing hair restraints to prevent foodborne illness and contamination. The facility's policies on food holding and service, as well as employee sanitation, were reviewed and indicated the need for serving hot foods at 135 degrees Fahrenheit or greater and the requirement for hand hygiene and hair restraints in the kitchen.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies in infection control practices. One incident involved a CNA who did not perform hand hygiene or change gloves while providing perineal care to a resident, despite the resident having multiple health conditions including multiple sclerosis and herpes viral infection. The CNA admitted to not following proper procedures, and both the ADON and DON confirmed that this failure placed the resident at risk for infection. The facility's policy required hand hygiene and glove changes between clean and dirty tasks, which were not followed in this case. Another deficiency was observed when an LVN did not clean an electronic wrist blood pressure monitor between uses on two residents. The LVN also failed to perform hand hygiene after administering medications to one resident before checking another resident's blood pressure. The LVN acknowledged the importance of these practices to prevent the transfer of germs but admitted to not following them due to nervousness. The ADON and DON confirmed that the failure to clean equipment and perform hand hygiene could lead to the spread of infections. Additionally, the facility did not ensure that staff were aware of a resident's contact isolation precautions. Several staff members, including a housekeeper, an LVN, and a CNA, were observed not wearing PPE while interacting with the resident who had a staph infection. The ADON admitted to not conducting an in-service to update staff on the resident's change from enhanced barrier to contact precautions. The DON and Administrator confirmed that the lack of proper PPE use and hand hygiene placed residents at risk for the spread of infection.
Failure to Assist Resident with Grooming
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not provide assistance with the removal of facial hair for a resident with severe cognitive impairment. The resident, who had a BIMS score of 1 indicating severe cognitive impairment, was dependent on staff for all ADLs, including bathing and grooming. Despite being scheduled for regular baths, the resident was observed with long chin hairs, and staff interviews revealed that the CNAs and nurses had not noticed or addressed the facial hair removal as part of the resident's grooming routine. Interviews with the CNA, DON, LVN, ADON, and the Administrator confirmed that the resident did not refuse care and that it was the responsibility of the CNAs and nurses to ensure the resident was shaved during bathing. The facility's policy indicated that residents unable to carry out ADLs independently should receive services to maintain good grooming and personal hygiene. However, the failure to remove the resident's facial hair was observed over multiple days, indicating a lapse in the facility's adherence to its own policies and procedures for maintaining resident dignity and appearance.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in a locked compartment, accessible only by authorized personnel. During an observation, an unlocked medication cart was found in the hallway near the dining room entrance, with multiple residents around. LVN A, who was responsible for the cart, acknowledged that it should always be locked when unattended to prevent unauthorized access. The ADON and DON confirmed that medication carts should be locked when staff are away from them, emphasizing the importance of preventing residents or unauthorized individuals from accessing the medications. The facility's policy also indicated that medication carts should be kept closed and locked when out of sight of the medication nurse or aide. Interviews with the ADON, DON, and Administrator revealed that they conduct daily rounds to ensure medication carts are locked and address any lapses with the staff. Despite these measures, the unlocked medication cart posed a risk of residents or unauthorized individuals accessing medications, which could lead to misuse or overdose. The facility's failure to secure the medication cart as per their policy and regulatory requirements was identified as a deficiency.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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