Falcon Lake Nursing Home, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Zapata, Texas.
- Location
- 200 Carla St, Zapata, Texas 78076
- CMS Provider Number
- 676214
- Inspections on file
- 30
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Falcon Lake Nursing Home, Llc during CMS and state inspections, most recent first.
A resident with ESRD on dialysis, diabetes with foot ulcers, heart failure, and depression, who was cognitively intact and independent in self-care, was issued a 30‑day discharge notice related to non‑payment and behavioral concerns. The notice, however, specified a discharge date only a few days after issuance rather than 30 days later. Social services documented active planning for the resident’s move to an apartment and coordination with community providers, but the resident was hospitalized before the 30‑day period elapsed. When the hospital prepared to discharge him back, facility leadership informed the Ombudsman that the owner did not want to take him back and did not want to honor the 30‑day notice, and the resident was not readmitted during the 30‑day window. Surveyors found this constituted a failure to provide a proper 30‑day discharge date and a failure to readmit the resident from the hospital within that 30‑day period, violating discharge requirements.
A resident with multiple chronic conditions and intact cognition received a 30‑day discharge notice that listed the reason for discharge and an effective date but omitted the discharge destination and the required contact information for the State LTC Ombudsman. The notice instead directed the resident to contact the ADM to initiate an appeal. The OMB confirmed the notice lacked Ombudsman information, and the resident reported receiving and disagreeing with the notice and pursuing an appeal. The ADM and DON acknowledged uncertainty about required notice contents, with the DON having obtained a template from an online search rather than following facility policy, which required inclusion of the discharge location and Ombudsman contact details.
A resident with multiple chronic conditions and intact cognition exhibited ongoing inappropriate and disruptive behaviors, including vulgar and sexually inappropriate comments to staff, taking staff and facility belongings, moving furniture from other rooms, playing loud music that disturbed others, and recording staff with a phone. Despite documented behavior-related incidents and staff reports, the resident’s comprehensive care plan did not include any problem statements, goals, or measurable interventions addressing these behaviors, and staff responses were limited to verbal redirection and informal education. This was inconsistent with the facility’s policy requiring ongoing assessment and revision of person-centered care plans with measurable objectives and timetables.
Surveyors found a medication cart on one hall and a wound care cart near the nurse station unlocked and unattended, with multiple bulk medications, blister packs, and supplies easily accessible. A resident in a wheelchair was seated about a foot from the unlocked medication cart. An LVN acknowledged he had forgotten to lock both carts when stepping away briefly and recognized the importance of securing them to prevent resident access and potential illness. The ADON and DON confirmed that all medication and wound care carts are required to be locked when not in use, and facility policy states that all compartments containing drugs and biologicals, including carts, must be locked and not left unattended if open.
A resident with dementia and a history of repeated falls experienced two unwitnessed falls that were documented in the care plan and incident log but were not recorded on the discharge MDS assessment. The ADON and DON both indicated a lack of understanding and oversight regarding the proper coding of falls, resulting in inaccurate MDS documentation.
A resident with Alzheimer's and high elopement risk had incomplete and inaccurate documentation regarding her wander guard monitoring. Staff failed to ensure the guard was worn as per policy, with records showing unsigned sections and incorrect entries. The DON acknowledged gaps in training and policy implementation, impacting resident safety.
The facility failed to maintain food safety and sanitation standards, with issues including ice build-up in the kitchen freezer, dirty coffee cups, and unlabeled, undated, and expired food items in the nutrition room refrigerator. Staff interviews revealed a lack of awareness and responsibility for these issues, and facility policies on food storage and maintenance were not followed.
A resident with a PEG tube did not receive proper infection control care from an LVN, who failed to follow Enhanced Barrier Precautions and hand hygiene protocols. The LVN did not wash or sanitize hands or change gloves appropriately during the procedure, despite handling various items and recognizing redness at the PEG site. Interviews revealed a misunderstanding of infection control measures, despite regular training.
The facility failed to maintain a safe and sanitary environment in the laundry area, with issues such as difficult-to-open doors, suspected mold on walls, and a leaking washing machine attracting mosquitoes. Staff reported these problems to the maintenance supervisor, but they remained unaddressed. The administrator was unaware of the issues due to reliance on the maintenance supervisor's assurances and ineffective monitoring of the maintenance log.
Improper Discharge Notice and Failure to Readmit a Resident Within 30-Day Period
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was permitted to remain in the facility and not be transferred or discharged in violation of federal discharge requirements. The resident was an adult male with multiple serious chronic conditions, including type 2 diabetes with neuropathy and foot ulcers, end-stage renal disease on dialysis, heart failure, hypertension, major depressive disorder, and atherosclerotic heart disease. He had a BIMS score of 13, indicating no cognitive impairment, and was independent in self-care, using a walker and electric wheelchair. Active discharge planning toward community placement had been documented, and the resident had previously approached social services requesting assistance with a possible future discharge to live alone with services. The record shows that the resident was first issued a 30‑day discharge notice on one date in late January, which he appealed and won due to a technicality. Despite this, he remained behind on his Medicaid applied income payments for several months, accumulating a significant balance. On a later date in early March, the DON and administrator again issued a 30‑day discharge notice, citing continued non‑payment and ongoing behavioral concerns. However, the notice given on that date listed an effective discharge date only a few days later, rather than 30 days from the notice date. The resident and the Ombudsman both reported that the second notice was dated with a discharge date six days after issuance, and the Ombudsman stated the facility documented that he was to be discharged to an apartment. Social service notes on the same day as the second notice document extensive discussions with the resident about his planned move to an apartment, his lack of payment of applied income, and his conflicting statements about wanting to leave versus wanting to stay. The SW documented contacts with an apartment complex, home health agency, dialysis center, and other community resources, and noted that the apartment would be available around the 11th or 12th of that month. The resident was then sent to the hospital shortly after this planning. Before the 30th day from the second 30‑day notice had elapsed, the resident was ready for discharge from the hospital and expressed a desire to return to the original facility while he awaited finalization of his apartment. The Ombudsman reported that the administrator stated the owner did not want to take the resident back and did not want to honor the 30‑day notice. The facility did not readmit the resident when he was discharged from the hospital prior to the 30th day after the 30‑day notice, resulting in a failure to provide a proper 30‑day discharge date and a failure to readmit him during that 30‑day period as required. Throughout his stay, the record reflects multiple behavioral incidents, including verbal agitation, sexually inappropriate comments toward staff, attempts to enter restricted areas such as the medication room, going into other residents’ rooms, recording staff and residents on his phone, and frequent threats to report staff to the state. Staff, including CNAs, LVNs, the ADON, DON, and facility owners, reported feeling uncomfortable or unsafe due to his comments, recording behavior, and perceived threats. The facility owners and leadership cited these behaviors, along with his refusal to pay applied income, as reasons for pursuing discharge. However, despite these concerns and the ongoing discharge planning, the facility did not provide a discharge date that was 30 days after the 30‑day notice and did not allow the resident to return from the hospital before the 30‑day period expired, which surveyors identified as a failure to ensure the resident’s right to remain in the facility and to be transferred or discharged only in accordance with regulatory requirements.
Noncompliant Discharge Notice Lacking Required Destination and Ombudsman Information
Penalty
Summary
The facility failed to issue a compliant 30‑day discharge notice to a cognitively intact male resident with multiple diagnoses including type 2 diabetes, major depressive disorder, heart disease, end‑stage renal disease, and dependence on renal dialysis. Record review showed the undated 30‑day discharge notice listed the reason for discharge as the facility’s inability to provide appropriate care for his specific needs and included an effective discharge date and a brief statement about appeal rights directing the resident to contact the ADM. However, the notice did not specify the location to which the resident would be discharged and did not include the name, mailing and email address, or telephone number of the State Long‑Term Care Ombudsman. The facility’s own Transfer and Discharge Notice policy required that the written notice include the location of transfer or discharge and the Ombudsman’s contact information. Interviews confirmed these omissions and the staff’s lack of understanding of the required notice content. The Ombudsman reported receiving the 30‑day discharge notice by email and stated that the notice given to the resident did not contain Ombudsman information, even though regulations require it so residents can appeal. The resident reported receiving the 30‑day notice from the ADM and DON, understood the stated reason for discharge, disagreed with it, and had contacted the Ombudsman to appeal; he was not injured or in distress. The ADM acknowledged he did not know the notice should indicate the discharge location, was unsure whether the Ombudsman’s information was included, and stated he followed a template provided by the DON. The DON stated she was unsure what information the notice was supposed to contain and had obtained a template via a web search, rather than from facility policy, leading to a notice that did not meet the facility’s policy requirements.
Failure to Care Plan Resident’s Inappropriate and Disruptive Behaviors
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s inappropriate behaviors. The resident was an adult male with type 2 diabetes, major depressive disorder, heart disease, end stage renal disease, and dependence on renal dialysis, with an MDS BIMS score of 13 indicating intact cognition. The resident’s care plan, dated 01/30/26, did not include any problem, goals, or interventions related to inappropriate behaviors such as making rude or vulgar comments, taking facility or staff items, playing music loudly, or recording staff with his phone. Progress notes between 08/29/25 and 01/30/26 documented at least two behavior-related incidents: one where the resident used vulgar language and made sexually inappropriate comments to staff, and another where he removed furniture from other rooms and placed it in his own room, for which staff only provided education about safety. In interviews, the ADON and DON both confirmed that the resident had ongoing inappropriate behaviors, including making rude or sarcastic comments about staff bodies, taking staff meals and facility items (such as a nurse station chair) to his room, playing music loudly enough that other residents complained they could not sleep, and recording staff with his phone. The ADON stated staff verbally redirected the resident and asked him to use headphones at night, but she was unsure if these behaviors were care planned. The DON acknowledged that the behaviors were not included in the care plan, that staff only verbally redirected the resident, and that no other interventions were implemented. The facility’s own policy required a comprehensive, person-centered care plan with measurable objectives and timetables, and specified that assessments are ongoing and care plans are revised as resident information and conditions change, but this was not done for this resident’s behavioral issues.
Unlocked Medication and Wound Care Carts Left Unattended
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all drugs and biologicals were stored in locked compartments when not in use, as required by facility policy and professional standards. During an observation, a medication cart assigned to an LVN on the 400 hall and a wound care cart located by the nurse station were found unlocked and unattended. The surveyor was able to open the top drawers of both carts, confirming they were not secured. Multiple medications in bulk bottles, supplies, and blister packs were easily accessible for removal. A resident in a wheelchair was observed sitting approximately one foot away from the unlocked medication cart. In an interview, the LVN responsible for the 400 hall medication cart and the wound care cart stated he had forgotten to lock the carts when he stepped away briefly to get something. He acknowledged the importance of locking the carts to prevent residents from accessing medications and stated that if a resident obtained medications, they could take something they were not supposed to and become sick. The ADON and DON both stated that all medication and wound care carts should be locked when not in use, and that leaving them unlocked and unattended could allow unauthorized individuals to access the contents, potentially resulting in drug diversion or accidental ingestion. Review of the facility’s Storage of Medications policy confirmed that all compartments containing drugs and biologicals, including carts, must be locked when not in use and that carts used to transport such items must not be left unattended if open or otherwise available to others.
Failure to Accurately Code Resident Falls on MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status by not documenting two unwitnessed falls that occurred on 6/1/25 and 6/18/25. The resident, who had diagnoses including dementia, muscle wasting, repeated falls, muscle weakness, and gait abnormalities, was identified as high risk for falls. The comprehensive care plan and the facility's incident log both documented the falls, but the discharge MDS indicated that no falls had occurred since admission or the prior assessment. Interviews with the ADON and DON revealed that the falls were not captured on the discharge MDS due to oversight and a lack of understanding regarding the coding requirements for falls. The ADON acknowledged missing the falls section on the MDS and was unsure of the importance of capturing this information. The DON was also unclear about the look-back period for falls in the MDS and confirmed that the omission resulted in incorrect documentation. The CMS RAI Manual specifies that any falls since admission or the prior assessment should be coded, but this was not followed in this case.
Inaccurate Documentation of Wander Guard Monitoring
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, specifically regarding the monitoring of a wander guard. The resident, who had Alzheimer's disease and was at high risk for elopement, had a physician's order for a wander guard to be checked every shift. However, the monitoring administration records for February 2025 showed incomplete and inaccurate documentation, with unsigned sections and incorrect entries by staff. On multiple occasions, the resident's wander guard was found not on her person but in her walker bag, contrary to the facility's policy that it should be worn at all times. RN A inaccurately documented that the wander guard was in place when it was not, and other staff members, LVN B and LVN C, failed to document the wander guard checks during their shifts. Interviews with the staff revealed a lack of adherence to documentation protocols and an absence of a specific policy for wander guard placement. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were responsible for ensuring accurate documentation, but there was no clear policy or consistent training regarding wander guard monitoring. The DON acknowledged the importance of accurate documentation for resident safety and compliance with physician orders but admitted to gaps in staff training and policy implementation. This deficiency in documentation could potentially impact the care and safety of residents at risk for elopement.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in the storage, preparation, distribution, and serving of food. Observations revealed significant ice build-up in the kitchen freezer, which could potentially impede airflow and cause equipment failure. Interviews with staff indicated that the ice build-up had been a persistent issue since the previous year, and despite attempts to remove the ice, it continued to accumulate. The maintenance staff had not contacted a service company to address the problem, and the last service was conducted a year ago, which did not resolve the issue. Additionally, the facility did not provide clean coffee cups for residents, as all cups observed were heavily stained and scratched. The nutrition room refrigerator contained multiple unlabeled and undated food items, including cookies, fruit, jam, juice, bacon, cream cheese, and an energy drink. Some items were also expired, and there was no thermometer in the unit freezer to monitor temperatures. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed they were unaware of these issues and did not know who was responsible for monitoring the nutrition room refrigerators. The facility's policies on food storage and maintenance were not followed, as evidenced by the lack of labeling, dating, and proper storage of food items. The maintenance log was not available, and the Administrator was unaware of the freezer's condition and the lack of monitoring in the nutrition refrigerator. The facility's failure to maintain sanitary conditions and proper food storage practices could place residents at risk of foodborne illness and living in an unsafe environment.
Inadequate Infection Control During PEG Tube Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during PEG tube care for a resident. The resident, who was non-verbal, blind, and spoke only Spanish, had a PEG tube and was incontinent. During the care procedure, LVN A did not adhere to Enhanced Barrier Precautions (EBP) as recommended by the CDC for residents with indwelling medical devices. LVN A did not wash or sanitize her hands before or after the procedure, nor did she change gloves appropriately, which are critical steps in preventing cross-contamination and infection. During the observation, LVN A was seen handling various items and performing tasks without changing gloves or sanitizing her hands. She touched the feeding pump, bed control, and other supplies without following proper hand hygiene protocols. Despite recognizing the slight redness at the PEG site, LVN A continued to use the same gloves throughout the procedure, including when handling sterile gauze and securing the dressing with tape. This lack of adherence to infection control practices was acknowledged by LVN A, who admitted to not following the handwashing protocol and misunderstanding the requirements of EBP. Interviews with LVN A and the facility's administrator revealed gaps in understanding and implementation of infection control measures. LVN A admitted to confusion about EBP and acknowledged her failure to wash or sanitize her hands, which she recognized could lead to cross-contamination. The administrator expressed concern over the staff's non-compliance with infection control guidelines, despite regular training. The facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent infection spread, was not followed, contributing to the deficiency in infection control practices.
Laundry Room Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the laundry area, as observed during a survey. The entrance door to the laundry room was difficult to open and close, with deep grooves in the floor where the door dragged, and a hole in the wall where the door handle would hit. Another door lacked an inner handle, and a room inside the laundry had dark patches on the walls, suspected to be mold. Additionally, a washing machine was leaking water into a basin, attracting mosquitoes, and a stray cat was observed entering the laundry room due to the door not shutting completely. Interviews revealed that the housekeeping staff had been experiencing these issues for years and had reported them to the maintenance supervisor (MS) multiple times. The MS acknowledged being aware of the issues but had not addressed them due to other renovation work. The administrator (ADM) was unaware of the problems, as she relied on the MS's assurance that everything was fine. The facility's maintenance policy required maintaining the building in a safe and operable manner, but the handwritten maintenance log used for repair requests was not effectively monitored, and the ADM was unable to locate it.
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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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