Golden Villa
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Texas.
- Location
- 1104 S William St, Atlanta, Texas 75551
- CMS Provider Number
- 675490
- Inspections on file
- 41
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Golden Villa during CMS and state inspections, most recent first.
A resident with heart failure, heart disease, and hypertension was ordered carvedilol twice daily with specific BP and HR hold parameters and daily vital sign monitoring. The care plan required checking and documenting BP per MD order and holding the medication if values were below set parameters. Review of the MAR showed no BP or HR documentation for the evening carvedilol dose over an extended period, and the MAR lacked a designated area to record these vital signs for the second daily dose. The DON confirmed that untimed vital signs in nurses’ notes could not be linked to the medication administration, and a medication aide reported that although she checked BP and pulse before giving the evening dose, there was no place on the MAR to record them, resulting in incomplete clinical records contrary to facility policy.
A resident with severe cognitive impairment and dependence on staff for ADLs experienced a delay in incontinent care after a bowel movement, despite a care plan requiring assistance with toileting and hygiene every two hours and as needed. The resident was observed sitting in a wheelchair with stool-stained clothing and a noticeable odor, while a hospitality aide reported having notified a CNA about the need for changing approximately an hour earlier. The CNA went on break without informing an LVN of the resident’s need for care, and leadership later confirmed their expectation that incontinent care be completed before breaks and provided promptly, consistent with facility policy requiring necessary services to maintain grooming and personal hygiene.
The facility failed to ensure that nurse aides working more than four months were properly trained, competent, and certified within the required four-month timeframe. Two nurse aides were hired and worked full-time providing resident care, including incontinence care and bathing, before timely completion of the LTCR Nurse Aide Training and Competency Evaluation Program and without having taken or scheduled the CNA exam. The DON, Administrative Assistant, and Administrator each gave differing and incorrect timeframes for when aides must be certified, and the Administrative Assistant, who shared responsibility for tracking certification with the staffing coordinator, was unsure of the actual requirements. These practices conflicted with the facility’s written policy that prohibits using an aide for more than four months unless the aide has completed an approved training and competency evaluation program or has been deemed competent under federal regulations.
A resident with dementia and mobility issues was found to have a raised toilet seat missing an anti-slip rubber foot, causing instability. Staff interviews revealed there was no specific schedule or policy for checking the safety and function of equipment, and the issue had not been reported or documented.
A staff member was observed vaping between the nurse's station and a resident sitting area while residents were present, in violation of the facility's non-smoking policy. Interviews with staff and residents confirmed that the facility prohibits smoking and vaping inside, and that staff are only allowed to smoke in a designated outdoor area. The incident was directly observed by a surveyor, and the staff member involved denied remembering the event but acknowledged using vapes and cigarettes.
Staff, including LVNs and a medication aide, were found to have pre-popped medications from blister packs and placed them in cups labeled with resident names or left unlabeled, storing them in medication carts or leaving them in resident rooms. These actions were contrary to facility policy, which requires medications to be administered directly to residents without pre-preparation or unattended storage.
The facility failed to properly label and date food items in storage, did not ensure all staff wore required hair restraints while in the kitchen, and did not maintain cleanliness of kitchen equipment and surfaces. Observations revealed unmarked food in the cooler and freezer, staff entering the kitchen without hairnets or beard guards, and significant grease buildup on cooking equipment, with cleaning schedules not being followed or documented.
Multiple residents reported that meals were bland, repetitive, overcooked, and not served according to their preferences, with observations confirming issues such as mushy vegetables and soggy breading. Residents with various medical conditions, including cognitive impairment and malnutrition, expressed dissatisfaction with food quality and variety, and documentation showed ongoing complaints over several months. The Dietary Manager acknowledged the problems and lack of a food palatability policy, while meal observations by surveyors confirmed the deficiencies.
Two residents were placed at risk when one was found with a prohibited antimicrobial skin cleanser in her room, and another was transferred using a mechanical lift with the legs in the narrow position, contrary to facility policy and FDA best practices. Staff interviews revealed a lack of awareness regarding the proper procedures for both chemical storage and safe resident transfers.
Three residents requiring respiratory care did not have their oxygen cannulas or nebulizer masks properly covered when not in use, contrary to facility policy and professional standards. Two residents' nasal cannulas were left uncovered on oxygen concentrators, and another resident's nebulizer mask was left uncovered on a nightstand. Staff interviews confirmed responsibility for covering equipment and acknowledged infection control concerns.
A CNA failed to change gloves and perform hand hygiene during incontinent care for a resident with severe cognitive impairment and multiple chronic conditions. The CNA used the same gloved hands to handle both soiled and clean items, including the resident's clothing, bedding, and bed remote, contrary to facility policy and infection control standards. Staff interviews and policy review confirmed that proper procedures were not followed, resulting in a breach of infection prevention protocols.
A resident with severe cognitive impairment and chronic pain experienced pain after an LVN yanked her left arm during care, as witnessed by another resident. The resident reported the LVN was mean and abusive, and the incident was documented in facility records. Staff interviews provided conflicting accounts, but the facility's abuse prevention policy was not upheld in this instance.
A resident with a history of wandering was found outside the facility unsupervised, despite having a wander guard. The facility failed to investigate multiple elopements, did not document incidents, and did not notify the family or physician. Faulty alarm systems and inadequate staff response contributed to the deficiency, leading to an Immediate Jeopardy situation.
The facility failed to maintain an effective pest control program, resulting in a roach infestation affecting two residents. A resident with severe cognitive impairment reported seeing roaches in her living area, while another resident with moderate cognitive impairment found roaches in his clothing. Staff interviews revealed inadequate communication and housekeeping practices, contributing to the problem. The facility's pest control measures, including monthly exterminator visits, were insufficient to address the infestation.
The facility failed to ensure accurate MDS assessments for four residents, leading to potential risks in their care. Errors included incorrect weight coding, missing documentation of wounds and treatments, and unrecorded diagnoses of anxiety, depression, and medication use. Interviews with staff emphasized the importance of accurate MDS coding for individualized care plans and appropriate staffing.
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. This included unaddressed weight loss, wound care, and medication management for residents with significant health issues.
The facility failed to provide palatable, attractive, and safe food for seven residents, leading to complaints about the taste, lack of seasoning, and improper cooking. Despite measures to address meal preferences, residents continued to express dissatisfaction with the food quality.
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies in catheter and incontinent care. Staff did not change gloves or sanitize hands appropriately, risking the spread of infections among residents with severe medical conditions.
The facility failed to provide a homelike environment by not replacing missing slats from a resident's window blinds, causing discomfort and difficulty napping. Despite repeated requests, the issue remained unresolved for months, and the maintenance log did not list the room as needing repairs.
The facility failed to update the care plans for two residents to reflect their current medication regimens, leading to potential risks in their care. One resident's care plan incorrectly listed Eliquis instead of Aspirin, and another resident's care plan was not updated to show the discontinuation of Eliquis.
A facility failed to ensure a safe transfer for a resident with severe cognitive impairment and physical limitations. Staff members did not use a gait belt as required by policy, instead lifting the resident under her arms, which could cause harm. The DON and ADM were unaware of this practice, and staff competencies lacked proper training for two-person transfers.
A resident with anxiety, depression, and dementia was prescribed Duloxetine and Lorazepam without adequate behavior and side effect monitoring. The facility's DON and ADM acknowledged the oversight, emphasizing the importance of monitoring due to potential major side effects in the elderly. The facility's policy mandates ongoing documentation and monitoring, which was not followed in this case.
Incomplete Documentation of Vital Signs for Antihypertensive Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident receiving antihypertensive medication with specific vital sign parameters. The resident, an older adult with diagnoses including heart failure, heart disease, and hypertension, had an admission MDS showing a BIMS score of 9, indicating moderate cognitive impairment, and required substantial staff assistance for most ADLs. The resident’s care plan identified hypertension with associated risks and included interventions to administer antihypertensive medications as ordered, check and document blood pressure per MD order, and hold medication and notify the MD per facility protocol if blood pressure was below ordered parameters. Physician orders and the Nursing MAR for the month showed an order for carvedilol 3.125 mg by mouth every 12 hours at 8 AM and 8 PM, with instructions to hold the medication for systolic blood pressure less than 105, diastolic blood pressure less than 60, and heart rate less than 60, and to monitor vital signs daily. However, review of the MAR from 3/01/26 through 3/19/26 revealed no documentation of blood pressure or heart rate for the 8 PM carvedilol dose. The DON acknowledged that there was no place on the MAR to document a second set of vital signs for the 8 PM dose and that, although some vital signs appeared in nurses’ notes, they were not timed, so it was not possible to determine their relationship to the medication administration. A medication aide who typically worked the 2 PM to 10 PM shift stated that when administering medications with blood pressure and pulse parameters, she documented those vital signs on the MAR and that, if a medication was ordered more than once daily, there should be a place to document vital signs with each administration. She confirmed that there was no place on this resident’s MAR to document blood pressure or pulse for the 8 PM carvedilol dose, even though she reported checking them before administration. She further stated that if blood pressure and pulse were not documented, it was as if they were not checked, and there would be no way to tell if the medication was given within the physician’s parameters. The facility’s medication administration policy required medications to be administered as prescribed and for vital signs to be checked and verified, if necessary, prior to administration, underscoring the incomplete documentation for this resident’s evening carvedilol doses.
Failure to Provide Timely Incontinent and ADL Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and assistance with activities of daily living (ADLs) to a dependent resident. The resident was an elderly female with Alzheimer’s disease, dementia, and anxiety disorder, with a Comprehensive MDS showing a severely impaired BIMS score of 5 and a need for substantial/maximal assistance with toileting, dressing, and personal hygiene. Her care plan required assistance from one staff member for toileting every two hours and as needed, with incontinent care after each episode. On the cited date, surveyors observed the resident sitting in her wheelchair with pajama pants stained brown from the crotch area and a noticeable stool odor; she was fidgeting and trying to grab clean clothes from her bed, and her verbalizations were incomprehensible. A hospitality aide present in the room stated the resident had a bowel movement and that she had informed a nursing assistant about an hour earlier that the resident needed to be changed. Further interviews revealed that the nursing assistant who had been caring for the resident was on break and had not informed the LVN that the resident required incontinent care before leaving. The LVN stated that the nursing assistant should have reported the need for care so that the LVN or another CNA could provide it, and acknowledged that residents not being provided incontinent care promptly could result in skin breakdown. The DON and the Administrator both stated their expectation that resident care, including incontinent care, be provided before staff go on break and that such care be provided promptly, with managers responsible for oversight. The facility’s policy on quality of life and ADL care for dependent residents required that residents unable to carry out ADLs receive necessary services to maintain grooming and personal hygiene. The resident’s family member also reported that they often observed the resident’s clothing soaked in urine, indicating ongoing concerns with timely incontinent care.
Failure to Ensure Nurse Aides Met Training and Certification Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides working more than four months were trained, competent, and certified within the required four-month timeframe, as required by OBRA and the facility’s own policy. Record review showed that NA D was hired on 01/03/2024 and completed the LTCR Nurse Aide Training and Competency Evaluation Program on 12/31/2024, indicating she worked full-time providing resident care such as incontinence care and bathing before timely completion of the program. NA B was hired on 11/12/2024 and completed the same training program on 02/16/2025, also working full-time and providing similar resident care during this period. Both aides reported they had not tested to become CNAs and did not have test dates scheduled. Interviews with facility leadership revealed confusion and incorrect understanding of the required certification timeframe. The DON stated that nurse aides had up to one year to get certified, while the Administrator stated that nurse aides had two years from completion of skills training to become certified. The Administrative Assistant, who along with the staffing coordinator was responsible for ensuring aides were certified within required timeframes, reported uncertainty about what those timeframes were and noted that the facility had been without a staffing coordinator until the day of the interview. These actions and inactions occurred despite a written facility policy stating that no individual would be used as a nurse aide for more than four months unless competent and having completed an approved training and competency evaluation program, or otherwise deemed competent under the federal requirements.
Failure to Maintain Safe Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition for one resident who used a raised toilet seat. Observation revealed that the raised toilet seat was missing an anti-slip rubber foot on one of its legs, causing the seat to rock when weight was applied. The resident, who had dementia, COPD, anxiety, and moderate cognitive impairment, required supervision for transfers and used a walker as her primary mode of mobility. The care plan identified her as being at risk for falls and included the use of a raised toilet seat as an intervention. Interviews with facility staff indicated there was no specific schedule for checking equipment for function and safety. The maintenance director relied on staff to report broken equipment via clipboards and checked these twice daily, but there was no record of the missing anti-slip foot. The DON stated that the maintenance director was responsible for monthly equipment checks and completing work orders, but the administrator confirmed there was no policy regarding the functioning of essential equipment.
Staff Member Vaped Indoors in Violation of Facility Non-Smoking Policy
Penalty
Summary
A staff member was observed vaping inside the facility, specifically between the nurse's station and the resident sitting area, while residents were present. The staff member, when questioned, denied remembering the incident but acknowledged using vapes and cigarettes, and stated that staff were not allowed to vape inside the facility. Multiple interviews with other staff members, including CNAs, LVNs, the DON, and the Regional Nurse, confirmed that the facility is a non-smoking environment and that staff are only permitted to smoke in a designated area outside the building. The facility's policy explicitly prohibits smoking, including electronic cigarette products, inside the building for both residents and visitors. Despite the facility's non-smoking policy, the incident of vaping occurred in a common area, exposing residents and staff to vape fumes. Interviews with residents and staff indicated no prior issues with vaping inside the facility, and staff expressed varying levels of awareness regarding the risks associated with vaping indoors. The event was directly observed by a surveyor, and the staff member involved was identified and questioned about the incident.
Improper Pre-Popping and Storage of Medications by Staff
Penalty
Summary
The facility failed to ensure proper pharmaceutical services were provided, specifically in the dispensing and administration of medications by staff. Multiple instances were observed where medications were pre-popped from blister packs and placed into medication cups, which were then either left unattended in resident rooms or stored in medication carts prior to administration. On one occasion, five clear medication cups containing different residents' medications were found in a resident's room, with the medications intended for administration but apparently forgotten. Further observations revealed that staff, including LVNs and a medication aide, had pre-popped medications for multiple residents and stored them in labeled or unlabeled cups within medication carts. One LVN had 15 cups with different resident names and medications, while another had two cups with resident names written on the bottom. The medication aide had three cups with medications but no resident names. Staff members acknowledged during interviews that they were aware pre-popping medications was not permitted and that medications should not be dispensed prior to the time of administration. Record reviews confirmed that the facility's policy required medications to be administered safely and timely, with verification of the right resident, medication, dosage, time, and route before administration. The policy also stated that medications should not be left at the bedside or pre-prepared for later administration. These practices were not followed, as evidenced by the observations and staff admissions.
Failure to Maintain Food Safety Standards in Kitchen Operations
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, as evidenced by multiple observations and interviews. In the walk-in cooler and freezer, numerous food items were found without proper labeling or dating, including foam bowls with unknown contents, plastic containers with unidentified meats, and bags of various unmarked food items. The dietary manager acknowledged that the staff responsible for labeling and dating had been absent, and the replacement staff did not follow proper procedures. The lack of labeling and dating was confirmed by both observation and staff interviews, with the dietary manager stating that undated food could be served past its safe period and that all food should be labeled and dated according to policy. Additionally, the facility did not ensure that all staff entering the kitchen wore appropriate hair restraints. The Activity Director Assistant was observed entering the kitchen without a hairnet while food was being prepared and admitted to doing so daily, unaware of the requirement. Two male dietary aides were also observed assisting with meal service without facial hair coverings, despite having mustaches and chin hair. Both aides stated they did not wear facial hair coverings, with one citing discomfort and the other only wearing a mask when ill. The dietary manager confirmed that all staff, including non-dietary personnel, were expected to wear hairnets and beard guards in the kitchen, and that this had been communicated previously. The facility also failed to maintain cleanliness of kitchen equipment and surfaces. Observations revealed a significant greasy buildup on the oven doors, knobs, backsplash, and the shelf above the stove, with drops of grease hanging over areas where food was being prepared. The cleaning schedule, which required daily and weekly cleaning of kitchen equipment, was posted but showed no documentation of completed cleaning tasks for the observed period. The dietary manager confirmed that all equipment should be cleaned daily and that the lack of cleaning could result in contamination. These failures were corroborated by facility policies and training records, which outlined the requirements for food labeling, staff hygiene, and sanitation practices.
Failure to Provide Palatable and Attractive Food to Residents
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for the majority of residents reviewed. Multiple residents reported that the food was bland, mushy, overcooked, and repetitive, with some stating that their dislikes and preferences were not honored. Observations confirmed that vegetables were often overcooked and watery, and fried foods were tough or soggy. Residents also reported that the same foods, such as chicken, instant mashed potatoes, and green beans, were served repeatedly, and that meal variety and texture were lacking. Resident interviews revealed dissatisfaction with the quality and presentation of meals, with several residents stating that the food was not appealing or fit to eat. Some residents with moderate to severe cognitive impairment, as well as those with diagnoses such as dementia, stroke, heart failure, depression, and malnutrition, expressed that their dietary needs and preferences were not being met. Grievance logs and resident council minutes documented ongoing complaints about food quality, temperature, lack of variety, and failure to honor dislikes, with issues persisting over several months. During meal observations, surveyors and the Dietary Manager noted that food items such as country fried steak and Brussel sprouts were not prepared to an acceptable standard, with soggy breading and mushy vegetables. The Dietary Manager acknowledged awareness of the complaints and agreed with the observations but stated there was no food palatability policy in place. Despite in-service education and discussions with dietary staff, the issues with food quality and resident satisfaction remained unresolved at the time of the survey.
Failure to Prevent Accident Hazards and Ensure Safe Transfers
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents. In the first instance, a resident with moderate cognitive impairment and a diagnosis of dementia was found to have an antimicrobial antiseptic skin cleanser in her room on two separate observations. The resident was unaware of who placed the bottle in her room or its intended use. Interviews with staff, including an LVN, the Director of Nurses, and the Administrator, confirmed that such items are prohibited in resident rooms due to the risk of harm, especially for residents with cognitive impairment. Despite this, the item remained in the resident's room, and facility policies provided did not specifically address the prohibition of such chemicals in resident rooms. In the second instance, a resident with severe cognitive impairment, hemiplegia, and a history of falls required two-person assistance with mechanical lift transfers. During an observed transfer, CNA B and CNA C did not maintain the mechanical lift legs in the wide position while moving the resident from his wheelchair to the bed. CNA B was unsure of the purpose of spreading the lift legs and routinely moved the resident with the lift legs in the narrow position. CNA C and the DON both stated that the lift legs should be in the wide position for stability and safety, as per facility policy and FDA best practices. The Administrator also confirmed that the staff did not follow the correct procedure, which could have compromised the resident's safety. Record reviews showed that CNA B had previously demonstrated satisfactory performance in mechanical lift procedures, which included keeping the lift legs in the wide position during transfers. Facility policy and FDA guidance both require the lift base to be at its maximum open position to ensure stability and prevent accidents. Despite this, the observed transfer did not adhere to these protocols, and the staff involved were not fully aware of the safety rationale behind the procedure.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required such care, as evidenced by observations, interviews, and record reviews. Specifically, two residents who used oxygen concentrators did not have their nasal cannula tubing covered with a bag when not in use, and one resident's nebulizer face mask was left uncovered on a nightstand. These actions were inconsistent with professional standards of practice, the residents' care plans, and the facility's own policy on oxygen administration. For the two residents with oxygen concentrators, both had physician orders for oxygen therapy and required maximal assistance with activities of daily living. During observations, their nasal cannulas were found uncovered and, in one case, nearly touching the floor. Both residents were cognitively impaired and typically wore oxygen, but the unused cannulas on their concentrators were not protected as required. The third resident, who was cognitively intact and required supervision with activities of daily living, had a nebulizer and mask sitting on her nightstand without a protective bag. Staff interviews confirmed that nurses and aides were responsible for ensuring respiratory equipment was covered when not in use, and acknowledged that failure to do so could lead to infection control issues. The facility's policy required safe handling and storage of respiratory equipment, but this was not followed in these instances.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control practices during incontinent care for a resident with severe cognitive impairment, multiple chronic conditions, and total incontinence. The CNA, after performing perineal care, did not change gloves or perform hand hygiene before handling clean items such as the resident's clothing, clean brief, clean incontinent pad, bedding, and bed remote. This sequence of actions was observed directly and confirmed through interviews with staff, who acknowledged that the CNA did not adhere to established protocols for glove use and hand hygiene. The resident involved was an elderly individual with diagnoses including dementia, heart disease, diabetes, hemiplegia, and cerebrovascular disease, and was always incontinent of urine and bowel. The care plan identified a risk for skin breakdown due to incontinence. During the observed care episode, the CNA used the same gloved hands that had been in contact with soiled areas to touch the resident's shoulder, hip, clothing, bedding, and other clean items, and also failed to perform hand hygiene after removing soiled gloves and before donning new ones. Interviews with another CNA, the Director of Nursing (DON), and the Administrator confirmed that the expected practice was to change gloves and perform hand hygiene when moving from a dirty to a clean area, and before handling clean items. Facility policies reviewed also required hand hygiene and glove changes at appropriate points during resident care. The CNA's failure to follow these procedures was acknowledged by the staff involved and was documented as not meeting the facility's infection control standards.
Failure to Protect Resident from Abuse During Care
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when a licensed vocational nurse (LVN) yanked the resident's left arm during care. The resident, an elderly female with diagnoses including parkinsonism, dementia with severe cognitive impairment, osteoarthritis, and chronic pain, required maximal assistance with activities of daily living. The incident was reported to have caused pain in the resident's left arm, which was already affected by chronic conditions, and was witnessed by another resident who described the action as abusive. Interviews and record reviews confirmed that the resident expressed feeling hurt and described the LVN as being mean and abusive, specifically mentioning repeated yanking of her left arm. The witness corroborated the account, stating that the LVN yanked the resident's arm in an abusive manner while administering pain medication. The resident reported ongoing pain in her arm following the incident, although she acknowledged pre-existing pain in that area. The facility's documentation included an incident report and a subsequent x-ray, which did not reveal acute injury but did confirm severe osteoarthritis in the affected shoulder. Staff interviews revealed differing perspectives on the incident, with the LVN denying any intent to harm and stating she was careful due to the resident's known pain. Facility leadership acknowledged the resident's sensitivity to her shoulder and noted that the witness supported the resident's account. The facility's abuse prevention policy requires protection of residents from all forms of abuse, but the actions described in the report indicate a failure to uphold this standard for the resident involved.
Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with a history of wandering. The resident, who was severely cognitively impaired and required supervision for various activities, was found approximately 50 feet away from the facility entrance around 4:00 AM. Despite having a wander guard and being identified as an elopement risk, the facility did not prevent the resident from leaving unsupervised. The facility did not investigate the resident's three separate elopements that occurred over several months. There was no documentation of these incidents in the resident's chart, nor were the family or physician notified. Staff interviews revealed that the resident had been found outside the facility on multiple occasions, yet these incidents were not properly reported or documented. The facility's alarm systems were found to be faulty, with issues in the wander guard system and door alarms that could turn off prematurely. Despite these problems, the facility did not take appropriate actions to address the risks, and staff failed to follow protocols for documenting and reporting elopements. This lack of action and oversight led to the identification of an Immediate Jeopardy situation.
Removal Plan
- Regional Nurse provided in-service training to Administrator on identifying an elopement, the importance of training staff to document any elopements, notifications required when elopements occur, the importance of facility investigating each elopement and placing intervention to prevent reoccurrence, the importance of facility elopement screening and assessments being completed accurately to determine wanderguard placement or potential secure unit placement, how to report an elopement to HHSC.
- In-services to all staff were initiated. Training will be conducted by administrator, ADONS, and Regional nurses. Topics covered include facility revised elopement policy. Policy addresses required assessments, documentation to complete, and notifications employees should contact.
- All in servicing will be completed. No employee will be allowed to work until in servicing is completed.
- Elopement policy will be included in new hire training packets.
- All resident's elopement screens and care plans were updated to ensure accuracy. Facility will follow elopement screen assessment guidelines for identifying level of risk. Facility screening tool provides a risk level numerical value based on key questions. All high-risk residents will be placed on Wander guard System. Audit and updates were completed by unit managers and ADONS.
- All residents that are on wanderguard will be identified in a binder at the nurse's station, with resident demographics (face sheet) to identify each. Completed by Unit managers and ADONS.
- Resident #1 was assigned a designated sitter until secure unit placement can be arranged.
- Facility adopted a new Elopement policy. The updated policy clearly defines steps for employees to take during an elopement. The new policy directs staff on necessary notifications to make, and all documents to complete. Incident reports and medical record entry are covered as well.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the environment of two residents. Resident #1, a female with severe cognitive impairment and multiple health issues, reported seeing roaches in her bathroom and around her living area. Her roommate corroborated these sightings, noting frequent bug activity in their shared space. Similarly, Resident #2, a male with moderate cognitive impairment, expressed concerns about roaches in his clothing and room. Observations confirmed the presence of roaches in Resident #2's room, with numerous insects seen on the sink and walls. Interviews with staff revealed systemic issues in pest control management. CNA KKK, who had been with the facility for three months, noted occasional roach sightings and attributed some of the problem to inadequate housekeeping practices. The Maintenance Supervisor acknowledged receiving verbal reports of roaches but did not consistently communicate these issues to the Administrator. The Director of Housekeeping admitted to seeing roaches in various facility areas and relied on verbal communication with the Maintenance Supervisor rather than maintaining a log of sightings. The lack of a structured deep cleaning schedule further contributed to the problem. The facility's pest control measures were insufficient, as evidenced by the exterminator's monthly visits not addressing the infestation effectively. The exterminator recommended keeping areas clean but did not provide specific instructions for deep cleaning or furniture management. The Administrator was unaware of the roach problem, despite expectations for a clean environment. The facility's policy on pest control, dated 2020, outlined measures to eradicate pests, but these were not effectively implemented, leading to an unsanitary environment for residents.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for four residents, leading to potential risks in their care and services. For Resident #61, the MDS was inaccurately coded with a weight of 262 pounds, despite a recorded weight of 255.4 pounds. Additionally, the MDS did not reflect the presence of a wound on the resident's left lower extremity, which was being treated as per physician orders. The care plans for Resident #61 also lacked documentation for the wound and weight loss, despite ongoing treatments and observations confirming these conditions. Resident #51's MDS was not coded to include diagnoses of anxiety and depression, despite these conditions being documented in the resident's medical records and care plans. Similarly, Resident #12's MDS did not reflect the use of the antidepressant Duloxetine, which was prescribed and administered regularly as per the physician's orders. The care plan for Resident #12 also failed to mention the use of this medication, despite its documented administration. For Resident #13, the MDS did not include active diagnoses of major depressive disorder and anxiety disorder, even though these conditions were documented in the resident's medical records and care plans. The resident was receiving medications for these conditions, but the MDS only reflected a diagnosis of bipolar disorder. Interviews with the MDS Coordinator, DON, and ADM highlighted the importance of accurate MDS coding for developing individualized care plans and ensuring appropriate staffing and care levels. The facility's policy on MDS accuracy emphasized the need for assessments to accurately reflect residents' statuses, as required by federal regulations.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #61, a 62-year-old male with diagnoses including wound infection, diabetes mellitus, and atrial fibrillation, did not have a care plan for his wound or weight loss despite significant weight reduction and specific wound care orders. Observations confirmed the presence of an open lesion on his left lower extremity, which was not addressed in his care plan. Resident #77, an elderly male with bladder cancer, diabetes mellitus, and obstructive uropathy, experienced weight loss that was not care planned. His quarterly MDS indicated moderate cognitive impairment and a need for supervision with eating, but no interventions were documented to address his weight loss. Similarly, Resident #12, an elderly female with depression and heart failure, had no care plan for her use of an antidepressant and diuretic, despite these medications being prescribed and administered regularly. Resident #30, an elderly female with hypothyroidism and heart failure, also lacked a care plan for her diagnoses and use of a diuretic. Her quarterly MDS indicated severe cognitive impairment and a need for maximal assistance with activities of daily living, yet her care plan did not reflect her medical conditions or medication regimen. Interviews with the MDS Coordinator, DON, and ADM revealed that care plans were not consistently updated or individualized, leading to potential risks for the residents involved.
Failure to Provide Palatable and Safe Food
Penalty
Summary
The facility failed to provide food that is palatable, attractive, and at a safe and appetizing temperature for seven residents. Multiple residents reported that the food tasted horrible, lacked flavor, and was sometimes improperly cooked. One resident mentioned that the chicken served was raw and bleeding, while another stated that the eggs were overcooked. Several residents expressed that they had to buy their own food due to the poor quality of the meals provided by the facility. The dietary manager acknowledged that the food needed more seasoning and flavoring, and residents had repeatedly requested different salt and seasoning mixes, which had not been provided by the facility. During a test tray sampling, the survey team and dietary manager found that the noodles were sticky and flavorless, the green beans were bland, and the chicken fried steak was soggy, although the gravy had good seasoning. The dietary manager confirmed the lack of seasoning in the food. Residents also reported that the food was often too soft and lacked variety, with some meals being mixed up, such as lunch and dinner. The facility's policies indicated that residents should be provided with nourishing, palatable, and well-balanced meals that meet their daily nutritional and special dietary needs, but these standards were not being met. Interviews with the Director of Nursing (DON) and the administrator revealed that they were aware of the food complaints but believed the food quality had improved. The DON mentioned that he had not received direct complaints from residents and that the facility monitored residents' weights to prevent weight loss. The administrator stated that a staff member inquired about residents' meal preferences daily and that alternate meals were available. Despite these measures, residents continued to express dissatisfaction with the food quality, indicating ongoing issues with the facility's meal services.
Infection Control Deficiencies in Catheter and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to several deficiencies in the care provided to residents. Specifically, the treatment nurse did not change her gloves or sanitize her hands appropriately while providing catheter care to a resident with multiple diagnoses, including sepsis and cellulitis. This failure was observed during an interview and record review, where the nurse admitted to not following proper procedures, which could have led to further infections for the resident. Another incident involved a CNA who did not change her gloves or perform hand hygiene correctly while providing incontinent care to a resident with severe cognitive impairment and chronic obstructive pulmonary disease. The CNA acknowledged her mistake during an interview, stating that she realized she should have changed her gloves but did not do so until later in the procedure. This lapse in infection control practices was confirmed by the DON, who emphasized the importance of universal precautions in preventing the spread of infections. A third deficiency was observed when a CNA did not change her gloves or sanitize her hands after removing a foley catheter stabilizer device from a resident with chronic kidney disease and urinary retention. The CNA admitted to being nervous and not following proper procedures, which included putting a dirty towel back into clean water. This was corroborated by an LVN who assisted during the procedure and confirmed that such actions could lead to urinary tract infections. The facility's policies and skills check-offs did not adequately address the need for changing gloves during these procedures, contributing to the observed deficiencies.
Failure to Maintain Homelike Environment by Not Replacing Window Blinds
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident by not replacing missing slats from the window blinds. The resident, who is [AGE] years old and has severe cognitive impairment, expressed that the missing slats allowed sunlight to enter the room, making it difficult for her to nap and causing discomfort. Despite the resident's repeated requests for the blinds to be fixed, the issue remained unresolved for months. The Maintenance Supervisor confirmed that the maintenance log did not list the resident's room as needing blind slats replaced, although other rooms had their blinds fixed. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged that facility policies require maintaining a homelike environment, which includes ensuring that window blinds are functional. The facility's policy on Quality of Life - Homelike Environment emphasizes the importance of providing a comfortable and personalized setting for residents.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plans for two residents were not updated to reflect their current medication regimens. Resident #12's care plan incorrectly indicated that she was prescribed Eliquis, while her records showed she was actually taking Aspirin. Similarly, Resident #13's care plan was not updated to reflect the discontinuation of Eliquis, which had been stopped on 04/08/24. Resident #12, an elderly female with a diagnosis of paroxysmal atrial fibrillation, had a care plan that indicated she was taking Eliquis, a blood thinner. However, her physician orders and medication administration records (MAR) showed that she was actually prescribed Aspirin. This discrepancy was not corrected in her care plan, which could lead to inappropriate care interventions. Resident #13, another elderly female with a history of gastrointestinal hemorrhage, had her Eliquis discontinued, but this change was not reflected in her care plan. Interviews with the MDS Coordinator, DON, and ADM revealed that they were aware of the importance of accurate and updated care plans for individualized resident care. They acknowledged that failing to update care plans could lead to residents not receiving appropriate care. The facility's policy on comprehensive person-centered care plans emphasized the need for ongoing assessments and timely updates, but this was not adhered to in these cases.
Improper Transfer Technique Used by Staff
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that two staff members, a CNA and an LVN, performed a safe two-person transfer for a resident with severe cognitive impairment and physical limitations. The resident, who required maximal assistance for transfers and was dependent on others for mobility, was transferred without the use of a gait belt, contrary to the facility's policy and the resident's care plan. Instead, the staff members lifted the resident from under her arms, a technique known as 'chicken winging,' which is not approved and could cause harm to the resident's arms and shoulders. The resident involved was an elderly female with diagnoses including dementia and age-related osteoporosis. Her care plan indicated that she required substantial assistance and was at risk for falls due to her medical conditions. Despite this, during an observed transfer, the staff did not use a gait belt and instead lifted her under her arms, which is against the facility's policy. The CNA involved stated that she believed using a gait belt was less safe for this resident, despite the policy requiring its use. The LVN also confirmed that the resident refused the mechanical lift, but did not authorize the omission of the gait belt. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were unaware of the improper transfer technique being used. Both confirmed that the facility's policy mandates the use of a gait belt for all transfers unless otherwise care planned. The DON emphasized that 'chicken winging' could cause damage to the resident's arms and shoulders, and the ADM acknowledged that improper transfers could lead to falls and injuries. The review of staff competencies showed that the CNA and LVN had not been checked off for two-person transfers, highlighting a gap in training and adherence to safety protocols.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure that Resident #12's drug regimen was free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Resident #12, an elderly female with diagnoses including anxiety disorder, depression, and dementia, was prescribed Duloxetine for depression and Lorazepam for anxiety. However, there were no orders for behavior or side effect monitoring for these medications, as confirmed by the resident's medical records and MAR. The care plan also did not indicate the use of an antidepressant, despite the prescription of Duloxetine. The Director of Nursing (DON) acknowledged the oversight and emphasized the importance of monitoring due to the potential major side effects of psychotropic medications on the elderly population. The Administrator (ADM) also confirmed that the nursing staff was responsible for ensuring medication and side effect monitoring, and that failure to do so could lead to unrecognized side effects and ineffective treatment outcomes. During interviews, both the DON and ADM highlighted the necessity of behavior and side effect monitoring to assess the efficacy of the medications and to report any adverse effects to the medical doctor (MD). The facility's Psychotic Medication policy from 2017 mandates ongoing documentation, including root cause analysis of behavioral indicators, monitoring for efficacy and adverse consequences, and documentation of target behaviors each shift. The lack of adherence to these protocols for Resident #12 indicates a significant lapse in the facility's medication management practices, potentially compromising the resident's therapeutic outcomes and safety.
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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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