Dfw Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 900 W Leuda St, Fort Worth, Texas 76104
- CMS Provider Number
- 455881
- Inspections on file
- 63
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 62 (4 serious)
Citation history
Health deficiencies cited at Dfw Nursing & Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, schizophrenia, and other psychiatric and neurological conditions, who was on multiple psychotropic meds and receiving psych and psych NP services, was issued a 30‑day discharge notice for behavioral reasons without clear clinical documentation that his needs could not be met in the facility or that he posed an unmanageable danger. Facility records showed intermittent behaviors, including medication refusals, yelling, room entry, and two physical incidents, with 1:1 monitoring and med adjustments but no documented evaluation of intervention effectiveness and no state incident report for a resident‑to‑resident altercation. The facility obtained an OPC to send the resident to an inpatient behavioral hospital and, after his psychiatric stabilization, refused readmission while discharge planning and communication with the hospital, a proposed group home, and the resident’s RP were inconsistent and conflicting, resulting in an unsafe and poorly coordinated transfer and discharge process.
Two residents with moderate cognitive impairment and psychiatric diagnoses engaged in a verbal and physical altercation after staff failed to effectively separate and de-escalate them, resulting in one resident sustaining a facial laceration that required hospital treatment.
A resident with severe cognitive impairment alleged that a nurse hit her during a shower, but the facility did not conduct a thorough investigation, failed to implement protective measures during the process, and did not maintain required documentation or report findings as mandated by state law and facility policy.
A resident's diagnosis of dementia was not accurately transcribed into the medical record, despite supporting documentation from hospitals and a physician. This omission led to incomplete records and contributed to the resident being able to leave the facility unsupervised, with staff unaware of the resident's absence. Interviews revealed that the process for entering diagnoses was inconsistent and not always completed promptly, resulting in gaps in care planning and documentation.
A resident with severe cognitive impairment and multiple medical conditions was subjected to repeated physical abuse by another resident with a history of aggressive behavior and psychiatric diagnoses. Despite documented risks and prior incidents, interventions such as 1:1 monitoring and safety checks did not prevent further assaults, resulting in actual harm and visible injuries to the abused resident.
A resident with severe cognitive impairment and multiple medical conditions was the victim of repeated assaults by another resident. Despite positive trauma screening results and ongoing behavioral concerns, the facility did not provide or refer the resident for behavioral health services or psychological assessment after the incidents. Staff interviews confirmed that no behavioral health interventions were initiated, and the resident's family observed increased withdrawal following the abuse.
A resident with schizophrenia and moderate cognitive impairment was immediately discharged to a behavioral hospital due to escalating violent behavior. Although the family was notified by phone, the ombudsman was not provided written notification of the transfer or discharge, and there was no documentation of attempted contact. Facility staff were unaware of the missed notification, and required discharge policies were not followed.
A female resident with severe cognitive impairment and a history of dementia was found partially undressed and confused in a male resident's room, who was cognitively intact and had a history of inappropriate behaviors. The male resident had previously attempted to enter other residents' rooms and was noncompliant with staff, but effective interventions were not implemented. The female resident was unable to consent, and staff and family confirmed her vulnerability. The facility failed to protect her from sexual abuse, despite documented warning signs and prior incidents.
The facility did not develop or implement comprehensive care plans addressing sexual activity and relationships for multiple residents, despite staff awareness of these relationships and interactions. Care plans lacked measurable objectives and interventions related to sexual behavior, and staff actions regarding consent and safe sex were not consistently documented or formalized in care plans.
A resident with cognitive impairment and a history of substance use alleged that another resident put drugs in her drink, leading to a hospital visit and police involvement. Despite staff and leadership being aware of the allegation, the incident was not reported to authorities within the required timeframe, as facility leaders believed there was insufficient evidence and questioned whether the event occurred on facility grounds.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables and specific actions, resulting in incomplete planning and documentation.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Nursing staff did not ensure that ordered laboratory tests, including CBC, CMP, lipid panel, Valproic acid, Hgb, and A1C, were obtained as scheduled for a resident with multiple medical conditions. There was no documentation of the labs being completed or refused, despite facility policy requiring completion and documentation of all physician orders.
A resident with dementia and a history of sexually inappropriate behavior was admitted without adequate care planning or interventions to address his behaviors. The resident inappropriately touched a student visitor, and staff and other residents reported ongoing discomfort and incidents, but facility leadership did not conduct a full investigation or report the incident as required. Staff were not properly trained or in-serviced on handling such behaviors, and interventions were inconsistently applied, resulting in a failure to protect residents and visitors from potential abuse.
A resident with dementia and a history of sexually inappropriate behaviors was admitted without a care plan addressing these issues. The resident engaged in inappropriate conduct toward staff, other residents, and a student visitor, causing discomfort and concern among others. Facility leadership did not recognize or act on the resident's history, failed to investigate or report incidents as required, and did not provide staff with adequate training or interventions to manage the behaviors, resulting in an Immediate Jeopardy situation.
A resident with multiple medical and behavioral conditions, including moderate cognitive impairment and a history of drug use, was able to obtain and use marijuana within the facility, resulting in an overdose and hospitalization. Despite prior knowledge of drug-related behaviors and reports from residents and staff about ongoing drug use, facility leadership did not implement effective supervision, investigation, or reporting measures, and there was no care plan addressing substance abuse for the resident.
Two residents with complex medical and behavioral histories did not have comprehensive, individualized care plans addressing all identified needs, including behaviors and substance abuse, despite documented incidents and staff awareness. Care plans were not updated to reflect significant changes or new behaviors, contrary to facility policy and regulatory requirements.
Two residents were involved in separate incidents that were not reported to the state agency or law enforcement as required. One resident with dementia and a history of sexually inappropriate behaviors inappropriately touched a student visitor, and the event was not reported despite staff and resident concerns. Another resident was found with signs of drug overdose and tested positive for marijuana, with prior concerns about drug use and distribution in the facility, but this was also not reported. The facility's leadership acknowledged awareness of these issues but did not initiate required investigations or reporting.
The facility did not thoroughly investigate or respond to allegations of abuse and drug use involving two residents. One resident with a history of sexually inappropriate behavior was not properly care planned or monitored, leading to an incident involving a student visitor that was not fully investigated or reported. Another resident was suspected of bringing drugs into the facility and was hospitalized for overdose, but no investigation or reporting occurred. Staff and other residents reported ongoing concerns, but the facility failed to follow its own policies for investigation and reporting.
Two residents with mild cognitive deficits and behavioral histories were placed together as roommates, resulting in a physical and verbal altercation that was not immediately reported or assessed by staff. The facility failed to prevent and promptly address resident-to-resident abuse, and no post-incident skin assessments were documented.
Surveyors found that the kitchen was not maintained in a clean and sanitary manner, with grease buildup, leaking pipes, and makeshift repairs using towels. Staff and management confirmed ongoing plumbing issues and delays in repair, and cleaning documentation was not provided as required by facility policy.
A large, uncovered hole behind the kitchen wall, left open during ongoing plumbing repairs, along with leaking sinks and dirty towels, resulted in an unsanitary kitchen environment. Staff interviews confirmed the hole was left open while awaiting the plumber's return, and the kitchen sewer system would flood when the sink was drained. These conditions placed residents at risk of exposure to infectious materials.
A resident with dementia and multiple mental health conditions was transferred to a behavioral hospital due to escalating behaviors. The facility did not provide timely written notification of the transfer or discharge to the resident's representative or the ombudsman, and the resident was unable to understand the notice due to cognitive impairment. Facility policies did not address the requirement for written notification to representatives.
A resident with moderate cognitive impairment and a history of trauma was involved in a physical altercation with the Administrator, who pushed the resident, resulting in a fall. The incident was not reported or documented until after surveyor intervention, and required notifications to the DON, corporate office, and state agencies were delayed, in violation of facility policy.
A resident with moderate cognitive impairment and multiple medical conditions was able to leave the facility unsupervised, as staff did not have interventions in place for wandering or elopement. The resident was last seen walking around the facility, was later found outside in cold weather without proper clothing, and required emergency medical attention after being returned to the facility.
A resident with schizophrenia and moderate cognitive impairment physically assaulted a staff member and the Administrator after feeling threatened by the Administrator's approach. The incident was not documented, reported, or uploaded to the state portal as required, and the DON was not informed until the following day by a family member. The Administrator, responsible for incident reporting, failed to complete the necessary reports or notifications.
A resident with schizophrenia and moderate cognitive impairment was involved in a physical altercation with the Administrator after being approached in a manner perceived as aggressive. The required incident/accident report was not completed on the day of the event, and there was no documentation in the resident's progress notes or assessments. The report was only initiated the following day after direction from the DON, and it remained incomplete, with missing notifications and documentation.
Two residents at the facility had inaccurate MDS assessments, leading to deficiencies in their care plans. One resident, with chronic kidney disease, had a discharge MDS that did not reflect his dialysis treatment, despite regular transport for it. Another resident, with COPD, had a quarterly MDS that failed to include his continuous oxygen therapy, despite consistent administration. Interviews with staff revealed acknowledgment of these documentation errors, highlighting the importance of accurate MDS records for comprehensive care.
The facility's kitchen failed to label and date food items in the reach-in refrigerator, including shredded cheese, sandwiches, and sliced ham, risking food-borne illnesses. Interviews with staff revealed non-compliance with the facility's food storage policy due to staffing issues.
A medication aide in a long-term care facility failed to follow infection control protocols while administering medications to a resident. The aide did not perform hand hygiene after checking the resident's blood pressure and used a bare finger to remove a tablet from a medication cup. Additionally, the aide administered eye drops without wearing gloves. These actions were not in compliance with the facility's infection control policies, as confirmed by the DON and ADM.
The facility failed to ensure a safe environment in the resident smoking courtyard by improperly storing a propane grill with two gas tanks, posing a fire hazard. Despite claims that the tanks were empty, a test showed the grill could ignite. Staff interviews confirmed the grill's use during a recent event, acknowledging the risk of fire or explosion. The facility's fire safety policy was not followed, contributing to the unsafe conditions.
A resident with hypertension was administered Nifedipine without proper blood pressure parameters, while Carvedilol was held due to a misunderstanding of the threshold. The medication aide failed to verify parameters with a nurse, leading to a deficiency in pharmaceutical services. The facility's policy on medication administration was not followed, contributing to the error.
A resident with multiple health conditions was administered Amiodarone 200 mg without checking vital signs, despite a warning to hold the medication if the heart rate was below 60 BPM. The administering MA was unaware of the requirement, and interviews with facility staff revealed a lack of clarity regarding the necessity of checking vital signs before administering heart medications.
A resident with a complex medical history experienced a fall and showed signs of increased lethargy and altered mental status, but the LTC facility failed to notify the physician and the resident's family. Despite staff observations of the resident's declining condition, the facility did not follow its policy to report significant changes, placing the resident at risk of not receiving immediate medical attention.
A resident with significant medical conditions, including hemiplegia and visual loss, did not have a call light within reach, as observed during a survey. Despite the care plan's intervention to ensure call light accessibility, it was found underneath the bed, out of reach. Staff interviews revealed that CNAs are responsible for ensuring call lights are accessible, but this was not adhered to, leading to a deficiency in care.
A resident with a history of hemiplegia, hemiparesis, and seizures was not provided with a fall mat as required by their care plan, despite being at risk for falls. The facility's staff, including the charge nurse and DON, were unaware of the omission, which was contrary to the facility's care plan policy requiring comprehensive, person-centered care plans.
A resident with extensive ADL needs did not receive scheduled bed-baths, going up to a week without proper hygiene care. Staffing shortages and inadequate documentation contributed to the issue, with the resident reporting disrespectful treatment by staff. The facility's policies for scheduled showers and timely responses were not followed, leading to this deficiency.
A resident with hemiplegia and hemiparesis was found without a call light within reach, and a fall mat was not provided as per the care plan. The resident, at risk for falls and with moderate mental impairment, was unable to communicate needs due to the call light being out of reach. Staff interviews revealed a lack of awareness and adherence to the care plan, despite facility policies requiring call light accessibility.
The facility failed to ensure proper incontinent care and catheter orders for three residents, who had indwelling urinary catheters without a physician's order. This oversight could introduce infection control issues.
Failure to Justify Discharge and Ensure Safe, Coordinated Transfer for Psychiatric Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was not transferred or discharged unless the transfer or discharge was necessary for the resident’s welfare, that the resident’s needs could not be met in the facility, or that the safety or health of others was endangered, and the failure to implement an effective discharge planning process. The resident was an adult male with Parkinsonism, seizure disorder, anxiety, depression, and schizophrenia, with a BIMS score of 03 indicating severe cognitive impairment and fluctuating delirium. His MDS and care plan documented mood issues, isolation, and a history of behaviors, including two prior aggressive incidents toward other residents, but also reflected that he had no documented ongoing physical or verbal aggression at the time of the 12/01/25 assessment. He was on multiple psychotropic medications and received psychological and psychiatric services, with a psychological note on 12/11/25 indicating no current risk factors for self-injury, sexual acting out, homicidal, or aggressive behavior, and describing him as engaged and interactive in therapy. Despite this, on 12/12/25 the facility issued a 30‑day discharge notice citing that the safety and health of other individuals were endangered and that the resident’s needs could not be met. The clinical record did not contain clear documentation that his needs could not be met in the facility or that he posed a danger that could not be managed through care planning or IDT interventions. Nursing notes from December 2025 through early February 2026 documented periodic behavioral concerns such as medication refusals, yelling, wandering into other residents’ rooms, verbal altercations, and two physical incidents: a shoulder bump of the maintenance director on 12/26/25 and pushing another resident on 01/12/26. The facility placed him on 1:1 monitoring after these events and notified the PMHNP, who adjusted his antipsychotic medication, but the nursing documentation did not reflect evaluation of the effectiveness of the increased antipsychotic dose or that identified behavioral interventions had been exhausted or found ineffective. The facility also did not report the 01/12/26 resident‑to‑resident physical aggression to the state incident system (TULIP). The facility then obtained an Order of Protective Custody and sent the resident to an inpatient behavioral hospital for psychiatric evaluation and stabilization, with the ADM stating the OPC was obtained because they “needed him out as soon as possible” and believed he was on the verge of harming someone. The resident’s RP reported not being informed of the transfer beforehand, not consenting to the transfer or discharge, and not being aware of any group home plan, while the SW and ADM described efforts to find alternate placement and a group home, and stated that the final decision not to accept the resident back after psychiatric hospitalization was made by the ADM. The behavioral hospital’s Director of Clinical Services reported that the facility had issued a 30‑day discharge notice, that the resident had been stabilized with no violent incidents for several days prior to an attempted discharge, and that the nursing facility communicated it would not accept the resident back, despite the resident still being legally their resident and without providing clear discharge planning assistance. Conflicting accounts and poor coordination among the facility, the behavioral hospital, the group home agency, and the RP resulted in the resident being discharged from the behavioral hospital without confirmed placement and being returned when a purported group home was found to be vacant. The surveyors found that the facility failed to ensure a safe and orderly transfer and discharge process and refused to readmit the resident after inpatient psychiatric stabilization, without adequate documentation that his needs could not be met or that he posed an unmanageable danger, and without an effective discharge planning process focused on his discharge goals and continuity of care.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. One resident, a female with moderate cognitive impairment and multiple psychiatric diagnoses, had a documented history of aggressive and inappropriate behavior towards other residents, including physical aggression and use of racial slurs. Her care plan noted risks for bleeding and bruising due to aspirin use, and previous incidents had required staff intervention to separate residents and assess for injuries. The other resident, a male also with moderate cognitive impairment and psychiatric diagnoses, similarly had a history of socially inappropriate and provocative behavior, including ramming his wheelchair into others. On the day of the incident, both residents encountered each other near the smoking area, exchanged words, and the female resident provoked the male resident by grabbing his pants and using racial slurs. Multiple staff members observed escalating verbal aggression, but the residents were not effectively separated or de-escalated before the situation became physical. The altercation resulted in the female resident sustaining a laceration above her eye, which required hospital treatment. Interviews with staff and residents revealed that the altercation involved both verbal and physical aggression, with the female resident striking the male resident and the male resident using his cane in self-defense, leading to the injury. The facility's failure to prevent the altercation, despite both residents' known behavioral risks and prior incidents, constituted a deficiency in ensuring residents' right to be free from abuse. Staff interviews indicated that while some attempts were made to separate and redirect the residents, these measures were not sufficient to prevent the physical confrontation and resulting injury.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse, protect residents during the investigation, and report the results of the investigation as required by state law. A resident with a history of major depressive disorder, anxiety, mood disorder, and schizophrenia, and with severely impaired cognition, reported that a nurse hit her while she was in the shower. The facility did not initiate an immediate investigation or implement protective measures for the resident or others while the allegation was being reviewed. Documentation showed that the resident became agitated during a shower, called staff names, threw objects, and refused assistance, eventually lying naked on the floor and repeatedly requesting to be sent to the hospital. Staff were unable to examine her for injuries or obtain vital signs due to her refusal to be touched. The nurse contacted the medical director, who ordered the resident to be sent to the hospital for further evaluation. There was no evidence that the facility conducted a thorough investigation into the abuse allegation or took steps to prevent further potential abuse during this period. Interviews with staff and review of facility records revealed that the required Post-Incident Report (PIR) and other investigation documentation were missing. The DON and administrator were unable to provide the PIR or any additional investigation records, citing that the previous administrator had not left the necessary paperwork. The facility's own abuse policy requires immediate reporting, thorough investigation, and documentation of all findings, none of which were completed or available for review in this case.
Failure to Accurately Transcribe and Maintain Resident Diagnoses
Penalty
Summary
The facility failed to accurately transcribe and maintain complete medical records for a resident, specifically omitting a diagnosis of dementia from the resident's records. The resident's face sheet and other clinical documentation did not reflect the dementia diagnosis, despite multiple sources, including hospital records and documentation from the resident's physician, indicating the presence of dementia. The omission was confirmed through interviews with facility staff, including the MDS coordinator and DON, who acknowledged that the diagnosis was not entered into the database prior to the incident and that the information was only uploaded after being provided by the resident's family. The deficiency was further highlighted when the resident, who had a history of cognitive impairment and a BIMS score indicating moderate impairment, was able to leave the facility unsupervised. The family was notified by a hospital that the resident had been there for two hours, while the facility receptionist was unaware of the resident's absence and initially reported the resident as present and fine. The facility's process for determining which residents require supervision when leaving the building relied on assessments and documentation that were incomplete due to the missing diagnosis. Interviews with staff revealed inconsistencies and a lack of clarity regarding the process for transcribing admitting diagnoses and updating resident records. The MDS coordinator and DON both indicated that the failure to enter the dementia diagnosis was due to missing or unreviewed paperwork at the time of admission. The facility's own policy required that all relevant medical information be documented promptly to ensure proper care planning, but this was not followed in the case of this resident, resulting in incomplete and inaccurate records.
Failure to Prevent Repeated Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease and dementia, from repeated physical abuse by another resident with a history of aggressive behaviors and severe cognitive impairment. The abused resident, who was independently ambulatory and had no behavioral symptoms, was subjected to three separate incidents of physical assault by the same peer. These incidents included being hit on the back of the head, being struck and subsequently falling to the ground, and being hit in the face, resulting in visible bruising, redness, and swelling. In one instance, the resident required evaluation at a local hospital, and in another, a facial x-ray was ordered due to the injuries sustained. The aggressor resident had a documented history of impulse control disorder, bipolar disorder, and other psychiatric and neurological diagnoses. Despite previous aggressive incidents, including hitting another resident and swinging a chair at staff and equipment, the interventions implemented by the facility, such as 1:1 monitoring and hourly safety checks, were not sufficient to prevent further assaults. The care plans for both residents acknowledged the risk of behavioral disturbances and the need for close observation, but the measures in place did not effectively prevent repeated abuse. Interviews with staff and family confirmed that the abused resident became more withdrawn following the incidents, and there was concern for her safety. The facility's policies required the protection of residents from abuse by anyone, including other residents, and mandated staff training in abuse prevention and management of aggressive behaviors. However, the repeated incidents of resident-to-resident abuse demonstrated a failure to ensure the resident's right to be free from abuse, as required by both facility policy and federal regulations.
Failure to Provide Behavioral Health Services After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident who was the victim of three separate incidents of resident-to-resident abuse. The resident, an elderly female with diagnoses including Alzheimer's disease, severe cognitive impairment, major depressive disorder, and chronic medical conditions, was assaulted on three occasions by another resident. Despite these incidents, there was no evidence that the resident received a psychology consultation or assessment following any of the assaults. Record reviews showed that the resident had a history of cognitive impairment and behavioral issues, such as intruding on others' privacy and taking personal items, but was not documented as having behavioral symptoms on her MDS. After each assault, interventions included 1:1 monitoring and trauma-informed screenings, which revealed positive responses indicating trauma. However, no referrals for psychological evaluation or therapy were made, even though the trauma screenings indicated the resident had experienced distress related to the assaults. Interviews with facility staff, including the social worker and DON, confirmed that no behavioral health referrals were initiated for the resident after the incidents. Staff cited the resident's advanced dementia and previous refusals of other services as reasons for not pursuing psychological services. The administrator stated that behavioral health services should be offered after such incidents, but this was not done. Family members reported the resident became more withdrawn after the abuse, but no behavioral health interventions were provided.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide written notification to the ombudsman regarding the transfer and subsequent discharge of a resident to a behavioral hospital. The resident, who had diagnoses including schizophrenia, unspecified psychosis, and major depressive disorder, was admitted with moderate cognitive impairment. Due to an escalation in verbal, physical, and violent behavior towards staff, the facility initiated an immediate discharge and transferred the resident to a hospital for psychological evaluation. Although the family member was notified by phone, the resident, who was his own responsible party, refused to give verbal consent for the discharge. Documentation review revealed that the social worker (SW) claimed to have contacted the ombudsman by leaving a voicemail regarding the immediate discharge, but there was no documentation of this action, nor could the SW provide a date for the attempted notification. Additionally, the SW could not produce a copy of the original 30-day notice or confirm its delivery. The ombudsman later confirmed that no notification was received before or after the resident's discharge. Interviews with facility staff, including the DON and ADM, indicated that they were unaware the ombudsman had not been properly notified. The facility's policy requires notification of the ombudsman for all discharges, but this was not followed in this instance. The lack of written notification to the ombudsman constituted a failure to ensure the resident's rights regarding transfer and discharge were upheld.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a female resident with severe cognitive impairment and a history of Alzheimer's disease, dementia, and stroke was not protected from sexual abuse by another resident. The female resident, who had a BIMS score of 3 indicating severely impaired cognition and was only sometimes able to be understood, was found in a male resident's room without underwear or pants, confused, and unable to walk unassisted. The male resident, who was cognitively intact with a BIMS score of 14 and a history of traumatic brain injury, depression, and drug use, was found in the same room with his pants and underwear down to his thighs. Staff discovered the situation after the female resident was reported missing from her room and a search was conducted. Prior to the incident, the male resident had exhibited concerning behaviors, including attempting to enter female residents' rooms, refusing redirection, and being noncompliant with staff instructions. These behaviors were documented in progress notes, but there was no evidence of effective interventions or increased supervision to prevent further incidents. The male resident's care plan included monitoring for sexually inappropriate behavior, but did not address his drug use or provide specific strategies to prevent access to vulnerable residents. The female resident's care plan noted her tendency to intrude on others' privacy and her cognitive limitations, but did not include interventions related to sexual safety or protection from other residents. On the morning of the incident, staff were unable to locate the female resident during routine rounds and initiated a search. She was eventually found in the male resident's room, disoriented and partially undressed, with physical signs of injury including a swollen lip and bruising. Interviews with staff and family members confirmed that the female resident was unable to make informed decisions or consent to sexual activity, and that the male resident had a history of inappropriate and threatening behavior. The facility failed to implement adequate protective measures despite documented warning signs, resulting in the sexual assault of a vulnerable resident.
Failure to Develop Comprehensive Care Plans for Resident Sexual Activity
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing sexual activity and relationships for several residents, despite evidence of known sexual relationships and interactions among residents. Specifically, five residents with varying degrees of cognitive impairment and mental health diagnoses were identified as being involved in sexual relationships or behaviors, yet their care plans did not include measurable objectives, timeframes, or interventions related to sexual behavior or relationships. The care plans reviewed either omitted this aspect entirely or only addressed unrelated behavioral issues. Interviews with staff, including the DON, ADON, and MDS Coordinator, revealed that while staff were aware of consensual sexual relationships among residents and sometimes provided education on consent and safe sex, these interactions were not consistently documented or care planned. Staff described providing privacy and condoms to residents they believed were capable of consenting, but there was no evidence of formal assessments or care plan interventions to guide staff actions or ensure resident needs were met in this area. Some staff believed care plans were in place, but upon review, these were either missing or incomplete regarding sexual activity. The facility's policy on care planning required the development of individualized, comprehensive care plans based on resident assessments, with input from the interdisciplinary team and, when possible, the resident and their representatives. However, the policy did not specifically address acute care plans for issues not covered by the comprehensive assessment, such as sexual relationships. As a result, the lack of care planning for known sexual activity among residents represented a failure to meet regulatory requirements for comprehensive, person-centered care planning.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported immediately, but not later than two hours after the allegation was made, as required by federal regulations. Specifically, a resident alleged that another resident put drugs in her beer, which led to her experiencing chest pain and being sent to the hospital. Despite the seriousness of the allegation, the facility did not report the incident to Health and Human Services within the required timeframe. The Director of Nursing (DON) and Administrator were both aware of the allegation but chose not to report it, citing the absence of evidence from hospital tests and the belief that the incident did not occur. The events leading to the deficiency involved two residents with complex medical and psychosocial histories. The resident making the allegation had diagnoses including bipolar disorder, anxiety, COPD, and a history of substance use and cognitive impairment. She reported feeling unwell after consuming a drink provided by another resident and subsequently called 911, resulting in police and ambulance involvement. Documentation shows that staff, including nurses and the ADON, were aware of the allegation and the resident's subsequent hospital visit, but the required abuse report was not made to the state agency. Interviews with facility leadership revealed a lack of clarity and consistency in handling the allegation. The DON admitted that the report was not made because hospital tests were negative, while the Administrator believed the incident occurred off-site and therefore did not require reporting. Both leaders demonstrated uncertainty about reporting requirements and failed to document their decision-making process. The facility's policy required reporting all allegations of abuse within the federally mandated timeframe, but this was not followed in this case.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on the absence of a comprehensive approach to care planning, as required, and was observed through review of the resident's records and care documentation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Obtain and Document Ordered Laboratory Tests
Penalty
Summary
Nursing staff failed to ensure that laboratory tests ordered by the physician were obtained as scheduled for a resident with multiple complex medical conditions, including metabolic encephalopathy, severe protein-calorie malnutrition, anemia, type 2 diabetes mellitus, bipolar disorder, and paranoid disorder. Specifically, orders for CBC, CMP, lipid panel, and Valproic acid to be drawn every six months, as well as Hgb and A1C every three months, were not carried out as required. Review of the resident's electronic clinical record revealed missing lab results for the specified periods, with no documentation to indicate that the labs were either completed or refused by the resident. The Director of Nursing (DON) confirmed that there was no evidence in the record to show that the blood draws were performed or refused, despite the resident's known history of refusing care and becoming combative. Facility policy requires that all physician orders, including labs, be completed as ordered and that refusals be documented. The lack of documentation and failure to obtain the ordered labs resulted in the deficiency cited by surveyors.
Failure to Prevent and Address Resident's Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to ensure a resident was free from abuse, neglect, and exploitation, specifically by not providing appropriate interventions and services to address the resident's ongoing sexually inappropriate behaviors. The resident, a male with dementia, metabolic encephalopathy, COPD, diabetes, chronic respiratory failure, end-stage renal failure, and hypertension, had a documented history of sexually inappropriate behavior at a previous facility, including recommendations for placement in a male-only locked unit. Upon admission, the facility did not care plan for these behaviors, and staff were unaware of the resident's history, despite clinical notes indicating prior sexual aggression. The deficiency was further evidenced when the resident inappropriately touched a student visitor during an activity, an incident that was reported to the DON and Administrator. However, the facility did not conduct a full investigation, report the incident to the state agency, or notify law enforcement. Interviews with other residents and staff revealed ongoing discomfort and reports of sexually inappropriate behaviors by the resident toward both staff and other residents, which had been reported to facility leadership without effective intervention. The care plan was not updated in a timely manner, and interventions such as 1:1 supervision were inconsistently implemented and not maintained. Additionally, the facility's abuse prevention policies and staff training were insufficient to address the specific risks posed by the resident's behaviors. Staff were not in-serviced on abuse/neglect and sexually inappropriate behaviors following the incident, and there was a lack of documentation and communication regarding interventions. The facility's failure to identify, investigate, and implement effective measures to prevent further incidents placed residents and visitors at risk of harm.
Removal Plan
- The DON, Social Services Director, and designee(s) interviewed/assessed all residents for potential abuse by conducting safe surveys on each resident.
- Resident evaluated by primary care provider and provided a medication update.
- Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted. Psych consult provided.
- Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible.
- IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions.
- Care plan revisions and interventions communicated to front line staff caring for resident.
- Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident.
- Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes.
- Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies.
- Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting.
- Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect.
- DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Process will be ongoing.
- In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Process will be ongoing.
- The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect. In-service will be ongoing.
- QAPI meeting will be held monthly, and findings discussed.
- The DON will monitor the effectiveness of interventions will be ongoing.
- A pre/posttest on abuse and neglect will be ongoing.
- The facility is still looking for proper placement of resident.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.
Failure to Prevent and Address Resident Sexual Abuse and Neglect
Penalty
Summary
The facility failed to develop and implement effective written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of a male resident with a history of sexually inappropriate behaviors. This resident, who had diagnoses including dementia, metabolic encephalopathy, COPD, diabetes, chronic respiratory failure, end-stage renal failure, and hypertension, was admitted without a care plan addressing his known sexually inappropriate behaviors. Despite documentation from a previous facility recommending placement in a male-only locked unit due to sexual aggression, the facility did not initially identify or address these behaviors upon admission. The resident engaged in sexually inappropriate conduct, including inappropriately touching a student visitor during an activity, making female residents uncomfortable with sexual gestures, and repeatedly being sexually inappropriate with staff. Multiple residents and staff reported feeling uncomfortable or unsafe due to the resident's actions, and these concerns were communicated to facility leadership. However, the facility did not implement effective interventions or services to address the resident's behaviors, nor did they in-service staff on how to properly handle such behaviors to prevent further incidents. The facility's leadership, including the DON and Administrator, failed to recognize or act upon the resident's history and ongoing behaviors. They did not conduct a full investigation or report the incident involving the student to the state agency or law enforcement, as required by policy. Additionally, the facility's abuse prevention policy was not fully implemented, and staff were not adequately trained or informed about handling sexually inappropriate behaviors beyond routine or initial training. These failures resulted in an Immediate Jeopardy situation, as residents and visitors were placed at increased risk for abuse and neglect.
Removal Plan
- The DON, Social Services Director, and designee(s) interviewed/assessed all residents for potential abuse by conducting safe surveys on each resident.
- Resident evaluated by primary care provider and provided a medication update.
- Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted. Psyche consult provided.
- Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible.
- IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions.
- Care plan revisions and interventions communicated to front line staff caring for resident.
- Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident.
- Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes.
- Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies.
- Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting.
- Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect.
- DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Process will be ongoing.
- In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Process will be ongoing.
- The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect. In-service will be ongoing.
- QAPI meeting will be held monthly, and findings discussed.
- The DON will monitor the effectiveness of interventions will be ongoing.
- A pre/posttest on abuse and neglect will be ongoing.
- The facility is still looking for proper placement of resident.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.
Failure to Prevent Resident Drug Use and Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with multiple complex medical and behavioral diagnoses, including COPD, multiple sclerosis, bipolar disorder, and legal blindness. The resident had a moderate cognitive impairment and required partial to moderate assistance with most activities of daily living. Despite being on parole for drug use and a sex offense, and after staff were informed by the resident's parole officer that he was bringing drugs into the building to sell to other residents, the facility did not implement effective interventions to prevent further incidents. The resident was found exhibiting signs of an overdose, including weakness, limpness, pinpoint pupils, confusion, and difficulty talking, and was subsequently transported to the hospital, where he tested positive for marijuana. Prior to this event, the resident had failed drug screenings, and the facility was aware of ongoing concerns about drug use among residents, as reported by multiple residents and staff. The facility did not have a care plan addressing the resident's behavior related to substance abuse, and there was no evidence of a thorough investigation or reporting to the state agency when drug use was suspected or confirmed. Interviews with residents and staff revealed that the smell of marijuana and reports of drug use were common, particularly during smoke breaks and in resident rooms. The Administrator and DON acknowledged awareness of these issues but did not take sufficient action to investigate, report, or prevent the introduction and use of nonprescription drugs within the facility. The facility's policy prohibited illegal drug use, but it was not effectively enforced, and staff were not in-serviced on recognizing or reporting signs and symptoms of drug use prior to the incident.
Removal Plan
- Resident #2 was assessed for signs or symptoms of drug use. MD was notified. Resident was drug tested.
- All residents will be in-serviced on the facility policy regarding illegal drug use.
- All residents will be assessed upon return from any leave from the facility for signs and symptoms of illegal drug use to include limpness on both sides of body, pinpoint pupils, confusion, and difficulty talking.
- All nursing staff will be in-serviced to perform and document the assessment upon return and if any signs and symptoms are noted the Administrator and DON will be notified, and the facility will follow the illegal drug use policy.
- The DON/designee will monitor the documentation for each resident return to ensure the assessments are complete.
- Resident is being discharged pending acceptance.
- The DON/designee will monitor the effectiveness of assessments completed of residents.
- QAPI meeting will be held and findings will be discussed.
- A pre/posttest will be completed by staff on signs/symptoms of drug use and ongoing.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.
Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by regulatory standards. For the first resident, who had multiple diagnoses including dementia, metabolic encephalopathy, COPD, diabetes, chronic respiratory failure, end-stage renal failure, and hypertension, the admission Minimum Data Set (MDS) assessment did not identify any physical or verbal behaviors. However, the resident had a history of socially inappropriate behaviors, specifically sexually inappropriate behavior, which was not addressed in the care plan upon admission. The care plan was only revised later to include interventions for these behaviors, indicating a delay in recognizing and planning for the resident's needs as identified in the comprehensive assessment. For the second resident, who had diagnoses including COPD, multiple sclerosis, bipolar disorder, and legal blindness, the care plan did not address the resident's substance abuse history or related behaviors. Despite documentation in progress notes that the resident was involved in bringing drugs into the facility and had an incident requiring transfer to the emergency room due to drug use, there was no corresponding care plan to address these behaviors. The resident himself admitted to a history of heavy drug use and recent marijuana use, and staff were aware of the incident and the ongoing risk, but this was not reflected in the care planning process. Interviews with facility staff, including the DON and MDS Nurse, confirmed that care plans were not updated to reflect significant changes or incidents, such as the emergence of new behaviors or substance abuse. The staff acknowledged the importance of updating care plans to ensure all care needs and interventions are communicated and implemented, but in these cases, the care plans did not include measurable objectives or timeframes to address the identified needs. This failure to update and individualize care plans was inconsistent with facility policy and regulatory requirements, as outlined in the facility's own policies and the CMS RAI Manual.
Failure to Timely Report Alleged Abuse, Neglect, and Drug-Related Incidents
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 no later than two hours after the allegation was made, as required by federal and state regulations. Specifically, two residents were involved in separate incidents that were not reported to the state agency or law enforcement as required. In the first case, a male resident with dementia and a history of sexually inappropriate behaviors inappropriately touched a student visitor during an activity. Despite being aware of the incident, the DON and Administrator did not report the event to the state agency, citing uncertainty about the details and lack of clear evidence from camera footage. Interviews with staff and residents revealed ongoing concerns about the resident's sexually inappropriate behaviors, which had been reported to facility leadership but not adequately addressed or reported. In the second case, another male resident with multiple diagnoses, including bipolar disorder and legal blindness, was found exhibiting signs of a drug overdose and was transported to the hospital, where he tested positive for marijuana. Prior to this event, there were documented concerns about the resident bringing drugs into the facility to sell to others, and a 30-day discharge notice had been issued due to non-compliance. Despite these concerns and the positive drug test, the facility did not report the incident to law enforcement or the state agency. Interviews with residents and staff indicated ongoing issues with drug use within the facility, with reports of marijuana and other substances being used during smoke breaks and in resident rooms. The Administrator and DON acknowledged awareness of these issues but did not initiate investigations or report the incidents as required. The facility's policy on abuse prevention requires the investigation and reporting of any allegations of abuse within the required timeframes. However, in both cases, the facility failed to follow established procedures for reporting suspected abuse, neglect, or exploitation. The lack of timely reporting and investigation of these incidents could place residents at risk for continued abuse or harm due to unaddressed allegations.
Failure to Investigate and Respond to Allegations of Abuse and Drug Use
Penalty
Summary
The facility failed to thoroughly investigate and respond to allegations of abuse, neglect, and exploitation for two residents. In the first case, a male resident with dementia and a history of sexually inappropriate behaviors was admitted without a care plan addressing these behaviors. Despite documentation from a previous facility recommending placement in a male-only secured unit due to sexual aggression, the facility did not implement appropriate interventions upon admission. The resident later inappropriately touched a student visitor during an activity, but the incident was not fully investigated or reported to the state agency. Staff and other residents reported ongoing sexually inappropriate behaviors, and the resident was only placed on Q15-minute monitoring after the incident. The Administrator reviewed camera footage but did not see conclusive evidence and therefore did not proceed with a full investigation or report the incident, despite policy requirements. In the second case, another male resident with multiple diagnoses, including bipolar disorder and legal blindness, was suspected of bringing drugs into the facility and selling them to other residents. The resident was found exhibiting signs of overdose and was sent to the hospital, where he tested positive for marijuana. Despite prior knowledge of the resident's behavior and reports from staff and other residents about drug use in the facility, there was no care plan addressing substance abuse. The facility did not initiate a thorough investigation or report the incident to the state agency. The Administrator and DON were aware of ongoing concerns about drug use, including the smell of marijuana during smoke breaks and packages suspected of containing THC, but did not take investigative or reporting actions. The facility's policy required investigation and reporting of all allegations of abuse, neglect, and exploitation, but these procedures were not followed in either case. Staff were not in-serviced on recognizing or reporting signs of drug use after the incidents, and there was no evidence of comprehensive investigations into the allegations. The lack of timely and thorough investigation and failure to implement effective interventions placed all residents at increased risk for abuse and neglect, as directly stated in the report.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident abuse, as evidenced by an incident in which the two roommates engaged in a physical and verbal altercation. Both residents had mild cognitive deficits, with one having a history of physical aggression towards staff and the other having a care plan addressing her relationship with a male companion. Despite these behavioral histories, the residents were placed together as roommates, which ultimately led to conflict. On the day of the incident, one resident was exiting the shared bathroom as the other attempted to enter, resulting in an exchange of words and a physical struggle where they grabbed each other's arms and hands. The altercation was not immediately reported to staff; instead, the residents resolved the issue themselves and only disclosed the event two days later. Interviews with another resident and review of incident reports indicated a pattern of previous verbal and physical altercations involving one of the residents. The facility's documentation revealed that no skin assessments were performed for either resident following the incident, and the care plans did not address the risk of resident-to-resident altercations. The facility's policy guarantees residents the right to be free from abuse and neglect, but the failure to prevent and promptly address the altercation between the two residents constituted a deficiency in protecting residents from abuse.
Deficient Kitchen Sanitation and Plumbing Maintenance
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to improper storage, preparation, and cleanliness of food service areas. Grease buildup was noted on the wall and floor behind the air fryer and stove, and towels that had turned brown were found wrapped around leaking pipes and under the pots and pans sink. Water was observed running into a hole where a pipe did not fit properly, and staff interviews confirmed that the pipes had been leaking for some time. The dietary manager and cook acknowledged ongoing plumbing issues and the use of towels to control water leakage, with maintenance and an outside plumber involved but repairs delayed. Documentation of cleaning schedules and staff assignments was requested but not provided before surveyor exit. Facility policy requires the kitchen and dining areas to be kept clean and sanitary, with regular cleaning schedules and staff training, but observations and interviews indicated these standards were not being met. A plumber's estimate and investigation confirmed that the kitchen sewer floods the floor when the three-compartment sink is drained, further contributing to unsanitary conditions.
Uncovered Kitchen Repair Hole and Unsanitary Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the kitchen area. Observations revealed a large, uncovered hole behind the kitchen wall, which had been dug by a plumber two weeks prior to address issues with the kitchen's plumbing. The hole remained uncovered because the plumber had not yet returned to complete the repairs, and the Maintenance Director (MD) stated that the hole was left undisturbed in anticipation of the plumber's return. Additionally, the kitchen environment was found to have leaking sinks and dirty towels, further contributing to unsanitary conditions. Interviews with facility staff confirmed that the plumber was responsible for the ongoing repairs and that the kitchen sewer system would flood the floor when the three-compartment sink was drained. The plumber's estimate indicated that the best option to prevent contamination was to cover the hole when work was not being performed, but this had not been done. The failure to cover the hole and address the unsanitary conditions in the kitchen could expose residents to infectious materials.
Failure to Provide Timely Written Notification of Transfer/Discharge
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to a resident's representative and the ombudsman, as required. Specifically, a resident with multiple mental health diagnoses, including dementia and schizoaffective disorder, was transferred to a behavioral hospital due to escalating verbal, physical, and violent behaviors. Although the resident received a discharge notification, her moderate cognitive impairment and dementia rendered her unable to understand the notice. The resident's representative and the ombudsman did not receive written notification prior to the transfer; the ombudsman only received verbal notification on the day of the transfer and written notification several days later. Attempts to contact the resident's representative were unsuccessful at the time of the transfer. Review of facility policies revealed that neither the Admission, Transfer, and Discharge Register Policy nor the Unmanageable Residents Policy included requirements for providing written notification of transfer or discharge to the resident's legally authorized representative. The deficiency was identified through interviews and record review, which confirmed that the required notifications were not provided in writing and in a manner understood by the resident or her representative prior to the transfer.
Failure to Protect Resident from Abuse and Timely Reporting
Penalty
Summary
The facility failed to protect a resident from abuse, specifically from a physical and verbal altercation with the Administrator. On the date of the incident, the Administrator pushed the resident, causing the resident to fall. The event was not reported or documented until after surveyor intervention the following day. The Administrator was not suspended until after the surveyor's involvement, and there was no immediate notification to the appropriate authorities or documentation in the resident's records regarding the incident. The resident involved had a history of schizophrenia, diabetes, and unspecified psychosis, with a moderate cognitive impairment as indicated by a BIMS score of 12. The resident's care plan identified a risk for altered status due to traumatic life experiences, particularly with male authority figures, and included specific interventions to reduce triggers. Despite these documented risks and interventions, the incident occurred and was not properly reported or documented in the resident's progress notes, assessments, or incident/accident reports. Interviews with staff and family members confirmed the altercation and the lack of timely reporting and documentation. Facility policy required that all occurrences affecting resident welfare, safety, or health be reported to appropriate agencies within 24 hours and that allegations of abuse be thoroughly investigated and reported. However, the Administrator, who was also the abuse coordinator, did not follow these policies, as the incident was not reported to the DON, corporate office, or state agencies in a timely manner. The Ombudsman and other required parties were not notified until after surveyor intervention, and the incident was not entered into the facility's reporting systems as required by policy.
Removal Plan
- Resident #1 was assessed by the Nurse.
- A thorough investigation was initiated by the Corporate Office and Director of Nursing Services.
- The Medical Director was notified by the DON.
- The DON called and left a message for the Ombudsman.
- The Responsible Party (RP) was notified by the Administrator.
- The accused Team Member was placed on Administrative Leave pending investigation.
- The Police Department was called and arrived at the facility.
- The Incident Report was completed.
- The SIMS was initiated.
- In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded), De-escalation of aggressive behaviors and resident to staff altercations.
- The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test.
- TEXAS Abuse hotline number posted in strategic areas within the facility, staff made aware of postings.
- Supervisor Rounds have been started to interview residents for issues related to care, respect and dignity.
- The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form.
- An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement.
- The Corporate Nurse Team will conduct a Zoom meeting with the Director of Nursing. The purpose of the in-service is to provide education for the following areas: Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director, Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse, Conducting Education and Training with all Departments, Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication, Five day follow up with the State Office.
- The Director of Nursing Services, or designee, will conduct a random audit of five residents weekly for four consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities.
- Findings of this audit will be reviewed in the Resident Council meetings.
- This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met.
Resident Elopement Due to Inadequate Supervision and Lack of Elopement Interventions
Penalty
Summary
A resident with a history of hyperlipidemia, schizophrenia, depression, anxiety disorder, parkinsonism, epilepsy, and unspecified behaviors, and who had a BIMS score indicating moderate cognitive impairment, was not provided with adequate supervision and assistance devices to prevent accidents. The resident's care plan did not reflect any wandering behaviors, and there was no indication that interventions for elopement risk were in place prior to the incident. On the date of the incident, overnight staff observed the resident walking around the facility and attempting to urinate in inappropriate places. The resident continued to wander and was last seen at 5:10 AM. Staff were unable to locate the resident during their rounds and initiated a search. The ADON was notified, and a code yellow was called. Despite searching the building and surrounding area, the resident was not immediately found. The police were notified, and staff continued searching outside the facility. The resident was eventually found by a staff member three blocks from the facility, barefoot and without a jacket, in cold weather conditions. Upon return, the resident was shivering, had very cold skin, and was nonverbal. The police called emergency medical services, and the resident was transported to the emergency room, where he was diagnosed with a viral upper respiratory infection and had an elevated blood pressure. There were no alarms heard by the ADON upon arrival, and the incident report confirmed the resident had eloped from the facility.
Failure to Timely Report Resident-to-Staff Physical Altercation
Penalty
Summary
The facility failed to immediately report an incident involving a resident with schizophrenia and moderate cognitive impairment who physically assaulted a staff member and the Administrator. The incident occurred when the resident, who had a history of being triggered by certain authority figures, felt threatened by the Administrator's approach and responded with physical aggression. Despite the occurrence, there was no incident or accident report completed, and no documentation of the event was found in the resident's records for the date in question. Additionally, the incident was not uploaded to the Texas Unified Licensing Information Portal as required. The Director of Nursing (DON) was not informed of the incident until the following day, after a family member reported it. The DON stated she was not responsible for incident reporting or uploading information to the state system, indicating that this was the Administrator's responsibility. However, the Administrator did not complete the required reports or notifications. As a result, the incident was not reported to the appropriate authorities in a timely manner, and there was a lack of documentation and communication regarding the event within the facility.
Failure to Timely Complete and Document Incident Report Following Resident Altercation
Penalty
Summary
The facility failed to ensure a complete and accurate incident/accident report was completed for a resident involved in a verbal and physical altercation with the Administrator. The incident occurred when the resident, who has a history of schizophrenia, diabetes, and moderate cognitive impairment, was approached by the Administrator in a manner the resident perceived as aggressive, leading to the resident physically striking the Administrator and subsequently falling to the floor. The resident's care plan indicated a risk for altered status due to past traumatic experiences and specified interventions for staff to follow, including calm approaches and contacting a family member if needed. Despite these interventions, there was no incident/accident report completed on the day of the event, nor was there documentation in the resident's progress notes or assessments regarding the incident. The incident report was only initiated the following day after the DON instructed the LVN to complete it, and it remained incomplete with missing notifications to agencies or people. Interviews with staff confirmed that the report should have been completed in the EHR under the resident's name on the same day as the incident, and the DON acknowledged that the responsible nurse is expected to document such incidents immediately or before leaving for the day. There was also no specific policy on documentation of incident reports in residents' medical records.
Inaccurate MDS Assessments for Dialysis and Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. Resident #1, a male with chronic kidney disease and dependent on dialysis, had a discharge MDS assessment that did not reflect his ongoing dialysis treatment. Despite having MD orders for dialysis on specific days, this critical information was omitted from his MDS, potentially impacting his continuity of care. Interviews and record reviews confirmed that Resident #1 was regularly transported for dialysis, yet this was not documented in his discharge assessment. Similarly, Resident #5, a male with COPD and other respiratory conditions, had a quarterly MDS assessment that failed to include his continuous oxygen treatment, as ordered by his physician. The resident's care plan and TARs indicated consistent administration of oxygen therapy, yet this was not captured in the MDS. Observations and interviews with Resident #5 confirmed the daily use of oxygen, highlighting the discrepancy in the MDS documentation. Interviews with the MDS/LVN and DON revealed acknowledgment of these documentation errors. The MDS/LVN admitted to missing the documentation of critical treatments for both residents, while the DON emphasized the importance of accurate MDS records for ensuring comprehensive care. The facility's failure to accurately document these treatments in the MDS assessments could lead to inconsistencies in care and potential risks for the residents involved.
Failure to Properly Label and Store Food in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Items in the reach-in refrigerator were not labeled with the name of the contents, use-by date, or expiration date. Specific items observed included a metal pot with shredded cheese covered by a ceramic plate, a Styrofoam plate with potato chips and two sandwiches, a block of cheese wrapped in plastic, a metal pan with meat pies covered in plastic wrap, and a metal pan with sliced ham that was uncovered. These lapses in labeling and covering food items could potentially lead to food-borne illnesses and contamination. Interviews with facility staff, including the Dietary Manager, DON, and Administrator, revealed a lack of compliance with the facility's policy on food storage. The Dietary Manager acknowledged that outside food should not be stored in the facility refrigerator and emphasized the importance of labeling and dating food to prevent food-borne illnesses. The DON confirmed that the expectation was for all food to be labeled, dated, and properly covered. The Administrator attributed the oversight to staffing issues, noting that kitchen staff had difficulty retaining employees, which led to missed procedures. The facility's policy, dated 2017, clearly stated that all foods stored in the refrigerator or freezer should be covered, labeled, and dated.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medication aide (MA A) during the administration of medications to a resident. The resident, a cognitively intact female with multiple diagnoses including anxiety disorder, breast cancer, and hypertension, was observed during a medication pass. MA A did not perform hand hygiene after checking the resident's blood pressure and before handling medications. He used his bare finger to remove a Coreg tablet from the medication cup, which he then discarded, and failed to perform hand hygiene afterward. Additionally, MA A administered eye drops to the resident without wearing gloves, further breaching infection control protocols. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that MA A's actions were not in compliance with the facility's infection control policies. The facility's policies require staff to perform hand hygiene before and after medication administration and to use gloves when administering eye drops. The facility's policy on administering medications and standard precautions emphasizes the importance of following infection control procedures to prevent the transmission of diseases and infections. These lapses in protocol could potentially place residents at risk of infectious diseases and cross-contamination.
Fire Hazard in Resident Smoking Area Due to Improper Grill Storage
Penalty
Summary
The facility failed to maintain a safe environment in the resident smoking courtyard, where a propane grill with two gas tanks was improperly stored. Observations revealed that one propane tank was attached to the grill, while another was positioned behind it. Despite claims from the Maintenance Director that the tanks were empty, a test showed that the grill could ignite, indicating the presence of gas. This situation posed a significant fire hazard, especially in an area where residents were permitted to smoke. Interviews with facility staff, including the Activity Director, Maintenance Director, CNA, Activity Assistant, Administrator, and DON, confirmed the presence of the grill and its use during a recent facility event. The staff acknowledged the potential risk of fire or explosion due to the propane tanks being connected to the grill. The facility's policy on fire safety and prevention, which requires flammable items to be stored in a locked metal cabinet, was not adhered to, further contributing to the unsafe conditions in the smoking area.
Failure in Pharmaceutical Services for Blood Pressure Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the administration of blood pressure medications. The resident, a cognitively intact female with a history of high blood pressure among other conditions, was prescribed Nifedipine and Carvedilol for hypertension. During a medication observation, a medication aide (MA A) administered Nifedipine but held Carvedilol due to the resident's blood pressure reading of 105/72, which was below the perceived threshold of 110. However, the medication aide did not realize that Nifedipine was also a blood pressure medication and should have been held as well. The medication aide admitted to not verifying the blood pressure parameters with a nurse, which could have prevented the administration error. The Licensed Vocational Nurse (LVN C) confirmed that neither medication had specified parameters for holding based on blood pressure readings. The Director of Nursing (DON) stated that the perceived parameter of 110 was a misunderstanding, as it was actually the ICD code for hypertension. The DON also mentioned that the physician did not require parameters for administering blood pressure medications, and the pharmacists advised that checking blood pressure before administration was unnecessary. The Medical Director was informed of the missing parameters and subsequently implemented a standing order with parameters for all blood pressure medications. The facility's policy on medication administration emphasized the importance of verifying medication details and consulting with the prescriber if there were concerns about potential adverse effects. Despite this, the medication aide did not follow the policy, leading to the deficiency in pharmaceutical services.
Failure to Check Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates and appropriate accessory and cautionary instructions. This deficiency was observed in the case of a resident who was administered Amiodarone 200 mg without checking vital signs or heart rate, despite a warning on the medication bubble card to hold the medication if the heart rate was less than 60 BPM. The medication was administered by MA B, who was unaware of the requirement to check the resident's heart rate before administration. The resident involved was an elderly female with multiple diagnoses, including atrial fibrillation, type 2 diabetes, and high blood pressure, among others. The resident had severe cognitive impairment, as indicated by a BIMS score of 3 out of 15. During the medication observation, MA B administered the medication without checking the resident's blood pressure and heart rate, stating that the parameters on the bubble pack were from an old prescription and that she was unaware of the current heart rate requirement. Interviews with facility staff, including an LVN and the DON, revealed that there was an expectation for staff to check vital signs before administering heart medications. However, there was a lack of clarity and communication regarding the necessity of checking vital signs, as the DON mentioned that the physician did not require BP parameters for medication administration. The Medical Director later acknowledged the missing parameters and emphasized the importance of checking vital signs before administering such medications.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify the resident's representative when there was a significant change in the resident's condition. This deficiency was identified for a resident who had a fall and showed signs of increased lethargy and altered mental status. Despite the resident's complex medical history, including encephalopathy, sickle cell, diabetes, stroke, and liver cirrhosis, the facility did not notify the physician or the family about the fall or the resident's declining condition. Interviews and record reviews revealed that the resident was admitted to the facility with a baseline of lethargy and moderate cognitive impairment. Throughout the week, the resident's condition deteriorated, with increased lethargy and decreased responsiveness. Staff members, including nurses and CNAs, observed these changes but failed to report them to the physician. The resident's family was also not informed of the changes, learning about the fall from the resident's roommate instead. The facility's policy required staff to notify the physician and the resident's family of any significant changes in condition. However, this protocol was not followed, as evidenced by the lack of documentation and communication regarding the resident's fall and altered mental status. The failure to notify the physician and family of these significant changes placed the resident at risk of not receiving immediate medical attention, which could have led to serious harm.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide a call light system within reach for a resident, identified as Resident #2, who was observed to have significant medical conditions including hemiplegia, hemiparesis, unspecified visual loss, seizures, and dysarthria following a stroke. The resident was also a right leg amputee and had a moderate mental impairment with a BIMS score of 10. The care plan for Resident #2 indicated a risk for falls and included an intervention to ensure the call light was within reach. However, during observations, the call light was found underneath the bed and out of reach, which the resident confirmed, stating he could not see well and was unaware of the call light's location. Interviews with staff, including a CNA, LVN, and the DON, revealed that the responsibility for ensuring call lights are within reach lies with the CNAs, who are expected to make rounds every two hours and check at the beginning and end of their shifts. The Administrator emphasized the importance of following care plans and keeping call lights accessible, especially for residents needing ADL assistance. The facility's call light policy also mandates that call lights be accessible from various locations, including the bed. Despite these guidelines, the failure to ensure the call light was within reach for Resident #2 was identified as neglect by the LVN.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #2, who was at risk for falls and injury due to a seizure disorder. Despite the care plan indicating the need for a fall mat in the resident's room while in bed, the facility did not provide this intervention. This oversight was identified through record reviews and interviews, revealing that the resident had not been offered a fall mat from the time of admission until the survey date. Resident #2, a male with a history of hemiplegia, hemiparesis, unspecified visual loss, seizures, and dysarthria following a stroke, was admitted to the facility with moderate mental impairment. Observations and interviews confirmed that the resident, who also had a right leg amputation above the knee, was not provided with a fall mat as required by his care plan. Interviews with the charge nurse and the Director of Nursing (DON) indicated a lack of awareness and understanding of why the fall mat was not in place, despite the expectation that care plans be followed. The facility's care plan policy mandates the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables to meet residents' needs, which was not adhered to in this case.
Failure to Provide Scheduled Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident who required extensive assistance with activities of daily living (ADLs). The resident, a male with a history of type 2 diabetes mellitus, morbid obesity, cerebral infarction, and osteoarthritis, was dependent on staff for personal hygiene due to his medical conditions. Despite being scheduled for bed-baths on Mondays, Wednesdays, and Fridays, the resident reported going up to a week without receiving a bed-bath. He also mentioned that staff sometimes informed him that he would not receive a bath on scheduled days, and he had never refused a bed-bath. Observations and interviews revealed that the resident's room had a strong smell of feces, indicating a lack of proper hygiene care. The resident expressed feeling disrespected by female staff who made fun of his size, which affected his self-esteem. Interviews with staff members highlighted issues with staffing shortages, which contributed to the failure to provide scheduled showers or bed-baths. The facility's shower log confirmed that the resident had not received a shower or bed-bath for six days, and there was no documentation of the resident refusing care. The facility's Director of Nursing (DON) and Administrator acknowledged the issue, with the DON stating that CNAs were responsible for ensuring residents received ADL assistance, including showers and baths. The Administrator emphasized the importance of offering showers every other day and expressed zero tolerance for residents not receiving their scheduled hygiene care. The facility's policies outlined the schedule for showers and the importance of timely responses to residents' needs, but these were not adhered to, resulting in the deficiency.
Failure to Ensure Resident Safety and Care Plan Adherence
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, the facility did not ensure that a resident, who had a primary diagnosis of hemiplegia and hemiparesis following a cerebrovascular disease, had a call light within reach. This resident, who also had a moderate mental impairment and was at risk for falls due to a seizure disorder, was observed without a call light within reach on multiple occasions. The call light was found underneath the bed, out of the resident's reach, which prevented the resident from communicating with staff when assistance was needed. Additionally, the facility did not provide a fall mat next to the resident's bed as indicated in the resident's care plan. Despite the care plan specifying the need for a fall mat due to the resident's risk for falls and injury, the resident reported never having been offered a fall mat. This oversight was confirmed by staff interviews, where it was revealed that the charge nurse and the Director of Nursing (DON) were unaware of the absence of the fall mat in the resident's room. Interviews with facility staff, including the charge nurse and the DON, highlighted a lack of awareness and adherence to the resident's care plan. The facility's call light policy required that call lights be accessible to residents, yet this was not followed. The Administrator expressed high expectations for care plans to be followed, but the deficiency in ensuring the resident's call light was within reach and the absence of a fall mat indicated a failure to meet these expectations.
Failure to Ensure Proper Catheter Orders and Care
Penalty
Summary
The facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices for three residents who had indwelling urinary catheters without a physician's order. Resident #1, a male with multiple diagnoses including obstructive uropathy and moderate cognitive impairment, had an indwelling catheter without a valid physician's order. His care plan included catheter care every shift, but the physician orders tab did not reflect an order for the catheter itself, only for catheter care and output monitoring. Resident #1 was observed with a catheter bag hung below his wheelchair, and he reported no issues with his catheter or care provided. Resident #2, a male with diagnoses including paraplegia and obstructive uropathy, also had an indwelling catheter without a physician's order. His care plan included catheter care every shift and monitoring of urine characteristics, but the physician orders tab only included an order to record urinary output from the catheter. Resident #2 was observed with a catheter at a local hospital but declined to speak with the surveyor. Similarly, Resident #3, a male with severe cognitive impairment and obstructive uropathy, had an indwelling catheter without a physician's order. His care plan included catheter care every shift and monitoring for signs of a urinary tract infection, but the physician orders tab only included an order for catheter care. The Assistant Director of Nursing (ADON) was unaware that these residents did not have the necessary physician orders for their catheters. The ADON stated that it was the responsibility of the admitting nurse to review admittance orders and notify the physician of the catheter, who would then write the necessary orders. The ADON acknowledged that not having these orders could introduce an infection control issue. The facility's policy on catheter care did not include verbiage regarding a valid rationale for the placement of an indwelling urinary catheter.
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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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