Focused Care At Cedar Bayou
Inspection history, citations, penalties and survey trends for this long-term care facility in Baytown, Texas.
- Location
- 2000 W Baker Road, Baytown, Texas 77521
- CMS Provider Number
- 676204
- Inspections on file
- 23
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Focused Care At Cedar Bayou during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities exhibited significant nighttime behavioral changes, including yelling, refusing care, and repeatedly attempting to get out of bed and crawl onto the floor. Staff placed a mattress on the floor for the resident to sleep on and documented that she would not stay in bed and was observed resting on the floor mattress. The following day, an LVN and CNA repeatedly observed the resident on the floor mattress, allowed her to continue sleeping there, and did not verify or ensure that the physician or MPOA had been notified of the behavior change or the mattress-on-floor intervention. Family members later reported they were not informed by staff that the resident was sleeping on the floor, and facility leadership and nursing staff acknowledged that the physician and family should have been notified of these changes, consistent with the facility’s Resident Rights policy requiring notification of changes in condition.
Surveyors determined that the facility failed to complete and share a baseline care plan for a newly admitted, cognitively impaired resident with multiple comorbidities (PVD, CHF, aphasia, DM2, hemiplegia, cerebral infarction, ESRD). The resident had an MPOA on file, but the baseline care plan, signed by the ADON, contained no documented preferences, including the resident’s stated need to sleep sitting upright rather than lying flat. The MPOA reported not receiving a summary of the baseline care plan. The DON stated that baseline care plans should be completed with a representative when a resident is cognitively impaired and acknowledged that omitting preferences and not providing a copy could lead to missed communication and lack of care. The Administrator acknowledged that the representative should have been involved and that a summary should have been provided per facility policy, which requires giving the resident and representative a baseline care plan summary with goals, meds, diet, services, and key health and safety information.
A resident with multiple chronic conditions experienced a significant decline, including low blood pressure, hypoglycemia, and increased lethargy. Despite abnormal vital signs and family concerns, nursing staff did not promptly notify the physician or document the changes as required. The resident was eventually hospitalized in critical condition with multiple organ failure.
A resident with diabetes mellitus and congestive heart failure experienced a significant decline in condition, including persistent hypotension, lethargy, and hypoglycemia, which was not promptly identified or addressed by nursing staff. Despite abnormal vital signs and repeated concerns from the resident and family, staff failed to follow care protocols and physician orders for monitoring and intervention, resulting in the resident's emergency hospitalization for multiple critical conditions.
A resident with diabetes had a critically high blood glucose reading, and the LVN administered insulin per the sliding scale but did not notify the PCP as required by physician orders and the care plan. There was no documentation of physician notification, and the DON was unaware of the incident until later. The facility's policy required prompt physician notification for such changes, which was not followed.
A resident with multiple comorbidities was administered Hydrocodone-Acetaminophen (Norco) after hospital discharge instructions had discontinued the medication. Due to failures in medication reconciliation and documentation, the resident received two doses of Norco within two hours instead of the prescribed six-hour interval. The resident became lethargic, experienced nausea and vomiting, and ultimately died after being transferred to the hospital for severe respiratory distress and cardiac arrest.
A resident with multiple comorbidities received Hydrocodone-Acetaminophen after it was discontinued post-hospitalization, due to failure to update the medication order and improper documentation. The resident was administered the narcotic more frequently than prescribed, became lethargic, experienced nausea and vomiting, and later died after being sent to the hospital. Staff did not reconcile hospital discharge orders with facility records, leading to a critical medication error.
A resident with multiple comorbidities received Hydrocodone-Acetaminophen after it had been discontinued, due to a failure to update the medication order in the chart. The medication was administered more frequently than prescribed, with inconsistent documentation between the eMAR and narcotic log. The resident developed lethargy, nausea, vomiting, and decreased responsiveness, ultimately experiencing respiratory distress and cardiac arrest, and expired at the hospital. Staff interviews and record reviews identified failures in medication reconciliation, documentation, and communication with the physician.
A resident with a history of chronic gout and other conditions was not provided with prescribed pain medication upon admission, despite repeated complaints of severe pain. The facility staff failed to follow up with the pharmacy and did not document or address the resident's pain, leading to an Immediate Jeopardy situation.
A resident with chronic gout, metabolic encephalopathy, type 2 diabetes mellitus, and stroke did not receive prescribed medications, including Eliquis and Hydrocodone-Acetaminophen, upon admission and for two days thereafter. Despite the medications being available, the facility failed to administer them, resulting in the resident experiencing continued pain and frustration.
A resident with significant cognitive impairment alleged that an LVN kicked her after she had fallen in her restroom. The facility's investigation confirmed that the LVN used her foot to restrain the resident, which was deemed abusive. The incident caused the resident pain and fear, and the LVN was terminated. The facility conducted in-service training for all staff on abuse, neglect, and exploitation following the incident.
A resident with severe cognitive impairment eloped from the facility despite wearing a wander guard. The facility failed to provide consistent one-to-one monitoring and did not adequately secure exit doors, leading to the resident being found across the street by law enforcement. Staff acknowledged lapses in procedure adherence and communication.
The facility failed to implement a baseline care plan for a newly admitted resident within 48 hours of admission. The resident, with multiple diagnoses including metabolic encephalopathy and type 2 diabetes, did not have a completed baseline care plan, which was confirmed by the MDS LVN and the DON. This failure could result in the resident not receiving necessary care and services.
The facility failed to document the use of a scoop mattress in a resident's care plan, despite the resident's high risk of falling and history of falls. This omission could lead to inconsistencies in care and place the resident at risk of not attaining or maintaining their highest practicable well-being.
A facility failed to maintain a medication error rate below 5%, resulting in a 6% error rate. A medication aide did not administer Sevelamer Carbonate and Carvedilol with meals as required, affecting a resident with hypertension and chronic kidney disease. Observations and interviews confirmed the medications were given without food, contrary to physician orders.
The facility failed to ensure that the dumpster lids and doors were secured, as observed with a commercial-size dumpster left completely open. Staff interviews confirmed that the dumpster should be closed to prevent trash from coming out and to keep unwanted items out. The Administrator expects the dumpster to be closed to avoid attracting pests. The facility did not provide their waste disposal policy before the exit interview.
Failure to Notify Physician and MPOA of Resident’s Behavioral Change and Mattress-on-Floor Intervention
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and medical power of attorney (MPOA) when there was a deterioration in the resident’s physical and mental status. The resident was an elderly female with multiple serious diagnoses, including peripheral vascular disease, heart failure, aphasia, type 2 diabetes mellitus, hemiplegia, cerebral infarction, and end stage renal disease. Her MDS showed a BIMS score of 00, indicating severe cognitive impairment. On admission, an RN documented that the resident was awake, alert, oriented x1, uncooperative, and combative. The baseline care plan behavioral section was blank, and the record contained an MPOA document naming two family members as healthcare agents. On the night in question, staff reported that the resident was up all night yelling, refusing care, and repeatedly attempting to get out of bed and crawl onto the floor. CNA G stated that the resident was difficult, would not stay in bed, and crawled down to the floor where she was restless and constantly tried to move around. A mattress was placed on the floor at the bedside so that the resident would not land hard on the floor, and an RN documented in an admission summary addendum that the mattress was left on the floor because the resident would not stay in bed and was observed sleeping on the mattress, appearing content there. Despite these significant behavioral changes and the use of a mattress on the floor as an intervention, there was no documentation that the physician or the resident’s representative was notified of the overnight behavior or the decision to have the resident sleep on a mattress on the floor. During the following day shift, LVN B received report from the night nurse that the resident had been up all night yelling and trying to get out of bed. On morning rounds, LVN B observed the resident resting quietly on the mattress on the floor and later documented that the resident remained resting, was compliant with wound care, and denied discomfort. CNA C reported checking on the resident multiple times, observing her breathing and appearing calm, and leaving the breakfast tray in the room after being instructed by LVN B to let the resident sleep. LVN B acknowledged she did not know whether the resident had an MPOA and did not verify whether the physician or representative had been notified of the overnight behavior or the mattress on the floor. Later that day, LVN B documented a change in condition: the resident was slow to respond, had audible moaning, required CPR, and was transferred to the emergency room after a weak, thready pulse and inability to obtain a blood pressure. Family interviews confirmed that the resident’s MPOA and another family member were not informed by facility staff about the resident’s restless nighttime behavior or that she was sleeping on a mattress on the floor. The MPOA stated he had visited the resident the prior evening and found her sitting in a wheelchair, smiling, and appearing fine, and that he only learned from another family member that the resident was on the floor. Facility leadership and nursing staff, including the ADON, DON, and RN D, stated that the physician and family should have been notified of the resident’s nighttime behavior, aggressiveness, inability to sleep, and the use of a mattress on the floor, and that they would have expected such notification for a change in condition. The facility’s Resident Rights policy stated that residents have the right to be notified of their medical condition and any changes in their condition. The surveyors concluded that the facility failed to immediately consult with the resident’s physician and representative when there was a deterioration in the resident’s physical and mental status, specifically regarding her restless nighttime behavior, repeated attempts to get out of bed, and the need for a mattress on the floor.
Failure to Complete and Share Baseline Care Plan Including Resident Preferences
Penalty
Summary
Surveyors found that the facility failed to develop and implement a complete baseline care plan and to provide a summary copy to the resident’s representative for one cognitively impaired resident. The resident was an elderly female admitted with multiple serious diagnoses, including peripheral vascular disease, heart failure, aphasia, type 2 diabetes mellitus, hemiplegia, cerebral infarction, and end stage renal disease. Her MDS showed a BIMS score of 00, indicating severe cognitive impairment, and her medical record contained an MPOA document naming a primary and secondary healthcare agent. Review of the baseline care plan, signed by the ADON, showed no entries under the section for additional comments or preferences. During interviews, the resident’s MPOA stated that the resident did not like to lie flat and preferred to sleep sitting upright, and that she could answer yes/no questions. He also stated he did not receive a summary copy of the baseline care plan. The DON stated that baseline care plans should be completed with a resident’s representative when the resident is cognitively impaired and acknowledged that not including preferences and not providing a copy to the representative could lead to missed communication and lack of care. The Administrator stated that a summary copy of the baseline care plan would be given to the resident or representative only if requested, and then acknowledged that the representative should have been included in the baseline care plan creation and that a summary should have been provided per facility policy. Facility policy required providing the resident and representative with a summary of the baseline care plan including initial goals, medications, dietary instructions, services and treatments, and information to properly care for the resident upon admission and address specific health and safety concerns.
Failure to Notify Physician of Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician of a significant change in the resident's condition. The resident, an older adult with a history of coronary artery disease, heart failure, hypertension, diabetes mellitus, and other chronic conditions, exhibited declining vital signs over several days, including persistently low blood pressure, low oxygen saturation, and episodes of hypoglycemia. Despite these abnormal findings, there was no timely physician notification or appropriate intervention documented by the nursing staff. The resident was noted to be increasingly lethargic, sleeping more than usual, and experiencing confusion and weakness. Family members expressed concern about the resident's condition and reported difficulty reaching him by phone. Nursing documentation indicated that the resident's blood pressure readings were repeatedly below normal, and his blood sugar dropped to hypoglycemic levels. However, staff did not consistently document these changes as a change in condition, nor did they promptly notify the physician as required by facility policy. Interviews with staff revealed a lack of awareness regarding the resident's diabetic status and confusion about when to notify the physician for abnormal vital signs. Ultimately, the resident's condition deteriorated to the point of requiring emergency transfer to the hospital, where he was found to be in acute hypoxic and hypercapnic respiratory failure, septic shock, acute renal failure, and persistent hyperglycemia. The hospital records indicated that the resident was critically ill with vital organ impairment or failure. The failure to recognize and act upon the resident's significant change in condition, including not notifying the physician in a timely manner, directly contributed to the severity of the resident's health crisis.
Failure to Identify and Respond to Acute Change in Condition in Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards of practice for a resident with multiple complex medical conditions, including diabetes mellitus and congestive heart failure. The facility did not properly identify or intervene in the resident's acute change in condition, despite clear evidence of declining vital signs and symptoms such as persistent hypotension, lethargy, and altered mental status over a period exceeding 24 hours. Nursing staff documented low blood pressure readings, low oxygen saturation, and changes in the resident's behavior, such as increased sleepiness and confusion, but did not consistently notify the physician or take appropriate action in a timely manner. The resident's care plan and physician orders required regular monitoring of blood glucose and blood pressure, with specific parameters for holding medications and notifying the physician of abnormal findings. However, blood sugar checks were not performed as ordered, and staff failed to recognize or respond to signs of hypoglycemia and hypotension. Interviews revealed that both the resident and family members repeatedly expressed concerns about the resident's condition and requested blood sugar checks, but these concerns were not adequately addressed by nursing staff. Documentation gaps were also noted, with missing nursing notes and incomplete follow-up on abnormal vital signs. The situation escalated when the resident's condition deteriorated further, resulting in critical laboratory findings and the need for emergency transfer to the hospital, where the resident was diagnosed with hypoglycemia, hyperkalemia, acute renal failure, septic shock, and respiratory failure. The delay in recognizing and responding to the resident's acute change in condition, as well as the failure to follow established care protocols and physician orders, directly contributed to the deficiency identified by surveyors.
Failure to Notify Physician of Critically Elevated Blood Glucose
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident with diabetes mellitus. The resident had physician orders and a care plan that required notification of the primary care provider (PCP) if blood glucose levels exceeded 401 mg/dL. On 6/9/2025, the resident's blood sugar was recorded at 403 mg/dL by an LVN, who administered the prescribed insulin dose but did not notify the PCP as required by both the care plan and physician orders. There was no documentation in the nursing notes or 24-hour report binder indicating that the PCP was notified of the elevated blood sugar level. Interviews revealed that the DON was unaware of the incident until after the fact and confirmed that the PCP should have been notified immediately. The LVN involved stated she was new and had not fully read the order, resulting in the failure to notify the PCP. The PCP confirmed he was not notified and would have provided further instructions if contacted. The facility's policy required prompt notification of the physician for changes in a resident's condition, including specific instructions to notify the physician, which was not followed in this case.
Failure to Discontinue and Appropriately Administer Narcotic Medication Leads to Resident Death
Penalty
Summary
A resident with multiple complex medical conditions, including hypotension, muscle weakness, type 2 diabetes, end stage renal disease, and dependence on dialysis, was readmitted to the facility following a hospital stay. Upon return, the hospital discharge summary included an order to discontinue Hydrocodone-Acetaminophen (Norco) due to concerns about generalized weakness, and this was noted in the resident's nursing notes. However, the Norco order was not discontinued in the facility's electronic medical record (eMAR), and the medication remained available for administration. On the day of the incident, the resident received two doses of Norco within a two-hour period, rather than the prescribed six-hour interval. The first dose was administered by one LVN and documented in the narcotic log but not in the eMAR. The second dose was given by another LVN, who, unaware of the previous administration, provided the medication again when the resident requested pain relief. This resulted in the resident receiving Norco more frequently than ordered. The error was later identified, and the physician was notified, who advised monitoring the resident. Documentation shows the resident became increasingly lethargic, experienced nausea and vomiting, and had a significant decline in responsiveness throughout the day. Despite monitoring and physician notification, the resident's condition continued to deteriorate, with vital signs indicating hypotension and decreased oxygen saturation. The resident was eventually transferred to the hospital due to severe respiratory distress, where she experienced cardiac arrest and expired. Interviews with staff revealed lapses in medication reconciliation, documentation, and adherence to physician orders, as well as failures to properly discontinue medications per hospital discharge instructions and to ensure accurate communication between shifts.
Failure to Discontinue and Accurately Administer Narcotic Medication Leads to Resident Death
Penalty
Summary
A deficiency occurred when the facility failed to provide proper pharmaceutical services, resulting in a resident receiving Hydrocodone-Acetaminophen (Norco) after it had been discontinued following a hospital visit. The medication was not discontinued in the resident's chart, and the resident received Norco more frequently than the order allowed. Documentation showed that the resident was administered Norco two hours apart instead of the prescribed six-hour interval, and the medication was not properly documented in the electronic Medication Administration Record (eMAR), leading to a double dosing incident. The resident involved was an elderly female with multiple complex medical conditions, including hypotension, muscle weakness, type 2 diabetes, end stage renal disease, dependence on dialysis, and chronic embolism and thrombosis. She was cognitively impaired and required assistance with activities of daily living. After returning from the hospital, her discharge instructions included discontinuation of Norco, but this was not reflected in her medication orders at the facility. As a result, she received Norco doses inappropriately, which was noted by staff when she became lethargic, drowsy, and experienced nausea and vomiting. Her condition deteriorated throughout the day, and she was eventually transported to the hospital, where she expired from cardiac arrest. Interviews and record reviews revealed that staff failed to reconcile hospital discharge orders with the facility's medication records, did not discontinue the medication in the system, and did not document administration properly in both the eMAR and narcotic log. There was confusion among staff regarding the resident's medication orders, and the lack of proper documentation and communication led to the administration of a discontinued and potentially harmful medication. The facility's policies required proper documentation and reconciliation of medication orders, but these were not followed, resulting in a critical medication error.
Failure to Prevent Significant Medication Error Leading to Resident Harm
Penalty
Summary
A significant medication error occurred when a resident received Hydrocodone-Acetaminophen (Norco) after it had been discontinued following a hospital visit. The discontinuation order was not properly entered into the resident's chart, resulting in the medication remaining active in the facility's records. Subsequently, the resident was administered Norco more frequently than the prescribed interval, with doses given two hours apart instead of the ordered six-hour interval. Documentation of medication administration was inconsistent, with one dose recorded in the narcotic log but not in the electronic medication administration record (eMAR), leading to a double dosing event. The resident involved was an elderly female with multiple complex medical conditions, including hypotension, muscle weakness, type 2 diabetes, end stage renal disease, dependence on dialysis, and chronic embolism and thrombosis. Upon readmission from the hospital, her discharge instructions included discontinuation of Norco, but this was not reflected in the facility's medication orders. The resident exhibited symptoms of lethargy, nausea, vomiting, and decreased responsiveness following the medication error. Staff noted the overdose and monitored the resident, but her condition deteriorated throughout the day, culminating in respiratory distress and eventual cardiac arrest. She was transported to the hospital, where she expired later that evening. Interviews and record reviews revealed lapses in medication reconciliation, documentation, and adherence to physician orders. Staff failed to ensure that discontinued medications were removed from the active medication list and did not consistently document administration in both the eMAR and narcotic log. There was also a lack of timely and effective communication with the physician regarding the resident's change in condition and the medication error. These failures directly contributed to the resident receiving a discontinued medication at an unsafe frequency, resulting in a significant adverse event.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services. Upon admission, the resident was prescribed Hydrocodone-Acetaminophen 10-325mg for pain, but the medication was not administered until several days later. During this period, the resident repeatedly complained of severe pain, which was documented by various therapists and staff members. Despite these complaints, there was no nursing documentation concerning the resident's pain, and the prescribed medication was not provided until a physician visited and changed the medication orders. The resident, who had a history of chronic gout, metabolic encephalopathy, type 2 diabetes mellitus, and stroke, was admitted to the facility and experienced significant pain due to a gout flare. The resident expressed that his pain was not being managed, which hindered his ability to participate in therapy. Multiple staff members, including therapists and nurse aides, were aware of the resident's pain but failed to ensure that the prescribed pain medication was administered. The admitting nurse reconciled the medications but did not follow up with the pharmacy, and subsequent nurses did not take appropriate action to address the resident's pain. Interviews with staff revealed a lack of communication and follow-up regarding the resident's pain management. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the facility's pain management policy was not followed, resulting in the resident experiencing unnecessary pain. The facility's failure to administer the prescribed pain medication and properly assess and document the resident's pain led to an Immediate Jeopardy situation, which was later addressed through corrective actions.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide routine and emergency drugs for a resident upon admission and for two days thereafter. The resident, who had a history of chronic gout, metabolic encephalopathy, type 2 diabetes mellitus, and stroke, did not receive his prescribed medications, including Eliquis (a blood thinner) and Hydrocodone-Acetaminophen (a pain medication). This resulted in the resident experiencing continued pain and expressing frustration over the lack of proper medication management. The admitting nurse reconciled and entered the resident's medication orders, but there was a failure in the follow-up process to ensure the medications were administered. Despite the medications being available in the facility's electronic dispensing machine, they were not given to the resident. Interviews with the nursing staff revealed a lack of proper follow-up with the pharmacy and physician to address the medication delay, and the resident's pain was not managed effectively. The Director of Nursing (DON) acknowledged the oversight and confirmed that the medications were available but not administered. The resident reported severe pain due to a gout flare and expressed dissatisfaction with the facility's handling of his medication routine. The failure to administer the prescribed medications as ordered led to the resident experiencing unnecessary pain and a decline in his quality of life.
Resident Abuse by LVN
Penalty
Summary
The facility failed to ensure that a resident remained free from abuse, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) and a resident with significant cognitive impairment. The resident, who had a history of falls and multiple medical conditions including dementia and major depressive disorder, alleged that the LVN kicked her in the side or back after she had fallen in her restroom. This incident was corroborated by another staff member who witnessed the LVN using her foot to restrain the resident and making verbally abusive comments. The resident reported feeling pain and fear as a result of the incident and expressed concerns about being hurt again by other staff members. The facility's internal investigation confirmed that the LVN had used her foot to restrain the resident, which was deemed inappropriate and abusive. The LVN admitted to using her foot to hold the resident down but denied kicking her. The investigation also revealed that the LVN had a history of training on abuse prevention, yet still engaged in behavior that constituted abuse. The facility's abuse policy clearly stated that residents should be free from any type of abuse, and the LVN's actions were in direct violation of this policy. Interviews with other residents and staff members indicated that while most did not have concerns about abuse, the incident with the LVN and the resident was an isolated but serious event. The facility conducted in-service training for all staff on abuse, neglect, and exploitation following the incident. However, the deficiency was identified as posing a risk for abuse, pain, fear, and psychosocial impairment for the residents, highlighting a significant lapse in ensuring a safe environment for all residents.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who eloped from the facility without staff knowledge, despite wearing a wander guard. The resident, who had a history of severe cognitive impairment and multiple medical conditions, was found across the street by law enforcement and returned to the facility. The resident's care plan included interventions for elopement risk, but these were not effectively implemented, leading to the incident. The resident's wander guard was not consistently checked for function, and the facility exit doors were not adequately secured to prevent elopement. Staff interviews revealed that the resident was supposed to be on one-to-one monitoring, but due to staffing shortages, this was not consistently provided. Additionally, the facility's exit doors, except for the front door, did not have alarms that would alert staff to an elopement. Observations and interviews indicated that staff were not always present to monitor the resident, and there were lapses in communication and procedure adherence. The facility's Director of Nursing (DON) and other staff acknowledged these failures, and the facility was found to be out of compliance, posing a risk of serious injury to residents due to lack of supervision.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to implement a baseline care plan for a newly admitted resident within 48 hours of admission. The resident, a [AGE] year-old male with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, stroke, and chronic gout, was admitted on [DATE]. However, no baseline or comprehensive care plan was completed for him. Interviews with the MDS LVN and the DON confirmed that the baseline care plan, which should have been completed within 48 hours, was not done. The incomplete baseline care plan was highlighted in yellow, lacked signatures, dates, and data, indicating it was not completed. The MDS LVN and the Administrator both emphasized the importance of the baseline care plan in ensuring continuity of care and meeting the resident's immediate needs. The facility's policy requires that a baseline care plan be completed within 48 hours of admission, including initial goals, physician orders, dietary orders, therapy services, social services, and PASARR if applicable. The failure to complete this plan could result in the resident not receiving the necessary care and services for health promotion and continuity of care.
Failure to Document Use of Scoop Mattress in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #57, which included the use of a scoop mattress. This deficiency was identified through observation, interview, and record review. The care plan did not document the use of the scoop mattress, which is intended to prevent falls or minimize the likelihood of falls. This omission could place the resident at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Resident #57, a [AGE] year-old woman, was admitted with multiple diagnoses including encephalopathy, cirrhosis of the liver, cerebral infarction, Parkinson's Disease, hypertension, aphasia, dysarthria, muscle weakness, difficulty walking, lack of coordination, cognitive communication deficit, and a displaced avulsion fracture of the left hip. The resident had a history of falls and was assessed as having a high risk of falling. Despite this, the care plan did not include any focus or intervention related to the use of a scoop mattress. Interviews with various staff members, including the ADON, MDS LVN, and DON, revealed that they were unaware of how long Resident #57 had been using the scoop mattress. They acknowledged that the use of a scoop mattress should be documented in the care plan to ensure all staff are aware of the necessary interventions. The failure to update the care plan with this critical information could lead to inconsistencies in the care provided to Resident #57, as staff may not know to obtain a scoop mattress prior to assisting the resident into bed.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate was not five percent or greater, resulting in a medication error rate of 6%. This was based on 2 errors out of 32 opportunities, involving one resident. Specifically, a medication aide (MA Q) did not administer Sevelamer Carbonate and Carvedilol to a resident as ordered by the physician, which required these medications to be given with meals. The resident, who had diagnoses including hypertension and chronic kidney disease, did not receive these medications with food as required, potentially affecting the therapeutic efficacy and safety of the medications. The resident's care plan and medication administration records indicated that Sevelamer Carbonate was to be given with meals to act as a phosphorus binder, and Carvedilol was to be given with food to slow absorption and prevent rapid blood pressure drops. Observations revealed that the medications were administered without food, and interviews with the resident and MA Q confirmed this practice. The resident had not eaten at the time of medication administration, and MA Q admitted to not following the specific instructions to give the medications with food. Interviews with the Director of Nursing (DON), the facility's Quality Assurance Pharmacist, and the Dialysis RN further confirmed the importance of administering these medications with food. The DON and the pharmacist highlighted the risks of not following the administration instructions, such as potential stomach upset and improper medication absorption. The Dialysis RN emphasized that Sevelamer needs food in the stomach to effectively bind phosphorus, preventing complications like weak bones due to high blood phosphorus levels.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly by not ensuring that the dumpster lids and doors were secured. This was observed on 02/09/2024 at 8:02 AM, when the facility's dumpster area had a commercial-size dumpster with the top lid completely open. During an interview on 02/12/2024 at 8:45 AM, DA BB stated that kitchen and housekeeping staff are responsible for taking trash to the dumpster and acknowledged that the dumpster should be closed when not in use, but sometimes it is not. Another interview on 02/12/2024 at 9:03 AM with HKM confirmed that the dumpster should be closed to prevent trash from coming out and to keep unwanted items out. The Administrator, interviewed on 02/12/2024 at 9:30 AM, also stated that she expects the dumpster to be completely closed to avoid attracting pests. The facility did not provide a copy of their policy and procedure for Waste Disposal/Dumpster before the exit interview.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
