Granbury Rehab & Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Granbury, Texas.
- Location
- 2124 Paluxy Hwy, Granbury, Texas 76048
- CMS Provider Number
- 455929
- Inspections on file
- 27
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Granbury Rehab & Nursing during CMS and state inspections, most recent first.
During a lunch meal service, residents did not receive all menu items, including macaroni salad, and two residents on pureed diets did not receive the required pureed roll. Staff did not inform residents of missing items or provide immediate substitutes, and documentation of substitutions was completed only after the meal. Multiple prior grievances indicated ongoing issues with missing or incorrect food items, and facility policies for menu adherence and substitution documentation were not followed.
The facility did not provide timely or documented responses to the Resident Council regarding multiple grievances related to nursing, dietary, and housekeeping services. Despite the facility's policy requiring communication of grievance outcomes, interviews and record reviews showed that Council members were not informed of resolutions, and issues remained unresolved. Staff cited unclear processes and workload as contributing factors to the lack of follow-up.
Three residents did not have care plans that accurately reflected their current needs and interventions, including one with a pressure ulcer whose care plan listed negative pressure wound therapy without a physician order or actual use, another on hemodialysis whose care plan lacked dialysis monitoring and collaboration details, and a third whose care plan did not match her transfer requirements or code status. Staff interviews confirmed these discrepancies and lapses in updating care plans.
The facility did not ensure its activities program was directed by a qualified professional, as the activity director lacked required certification or training and had not completed a state-approved course within the expected timeframe. The administrator was aware of the deficiency, citing financial and logistical delays as reasons for non-compliance.
The facility did not serve meals at the posted times, with lunch service significantly delayed and the last trays delivered nearly two hours after the scheduled time. Multiple residents reported ongoing issues with late meals, and staff interviews revealed there was no policy in place for meal service timing. The dietitian expected meals to be served within 45 minutes of the scheduled time, but this was not consistently met, as confirmed by observations and grievance records.
The facility did not ensure proper monitoring and documentation of food temperatures during meal preparation and service. Staff pureed hot foods with cold milk, resulting in temperatures below required levels, and failed to reheat or recheck temperatures before serving. Multiple meals lacked documented temperature checks, and dietary leadership confirmed that these practices did not meet policy or regulatory standards.
The facility did not complete or maintain required EMR/NAR employability checks for two staff members, including an RN and a dietary manager, prior to their hire as mandated by policy. HR staff could not provide documentation of the checks, and the administrator confirmed the policy was not followed for both direct hires and contracted staff with resident contact.
Two residents did not have baseline care plans developed or updated within 48 hours of admission as required. For one, the facility reused an old care plan without updating it to reflect new medical orders and did not obtain updated signatures. For the other, there was no evidence that a summary of the baseline care plan was provided to the resident or their representative. Staff interviews confirmed lapses in following policy for care plan creation and communication.
A medication cart containing various prescription drugs and medical supplies was left unlocked and unattended in a hallway for several minutes while the responsible LVN was distracted by a family member. The cart was within reach of staff and residents, and the ADON confirmed it should not have been left unsecured. Facility policy requires medication carts to be locked when not attended by authorized personnel.
Staff failed to perform proper peri-care and hand hygiene during incontinent care for a resident with a history of metabolic encephalopathy and cystitis. Two CNAs did not wash their hands or use sanitizer throughout the procedure, and one reused a wipe before discarding it. The involved CNA acknowledged not following protocol due to lack of hand gel in the room, and the DON confirmed that facility policy requires hand hygiene after glove removal and care.
During a lunch meal service, several residents did not receive all items listed on the menu, including macaroni salad and pureed rolls for those on special diets. Staff did not inform residents of missing items or provide immediate substitutes, and documentation of substitutions was completed after the meal. Multiple prior complaints about missing food items and lack of communication were also noted.
The facility did not provide verbal or written responses to the Resident Council regarding grievances about nursing, dietary, and housekeeping services. Documentation indicated that grievances were marked as resolved through 'one-to-one' discussions, but residents reported not being informed of outcomes, and staff interviews confirmed a lack of consistent follow-up or communication with the Council.
Three residents did not have care plans that accurately reflected their current needs and interventions, including one with a pressure ulcer whose care plan listed negative pressure wound therapy not being provided, another on hemodialysis whose care plan lacked monitoring and communication interventions, and a third whose care plan did not match her transfer requirements or code status. Staff interviews confirmed that these discrepancies were due to lapses in updating and maintaining care plans.
The facility did not ensure its activities program was directed by a qualified professional, as the activity director lacked required certification or training and had not completed a state-approved course within the expected timeframe. Financial and logistical barriers delayed the AD's enrollment in the necessary program, and the deficiency was identified during record review and staff interviews.
The facility did not serve meals at the posted times, with lunch service significantly delayed for all residents. Staff and resident interviews confirmed ongoing issues with late meal delivery, and the facility lacked a clear policy on meal service timing. Multiple grievances had been filed about late and cold meals, and observations confirmed that meal trays were not served until well after the scheduled time.
The facility did not ensure proper monitoring and documentation of food temperatures during meal preparation and service. Staff pureed hot foods with cold milk and failed to reheat them to the required temperature, and did not consistently check or record holding temperatures before serving. Interviews revealed inconsistent understanding of food safety protocols among dietary staff and management, and review of logs showed multiple instances of missing temperature documentation, placing residents at risk for foodborne illness as noted by staff.
The facility did not complete or maintain required EMR/NAR checks for two employees, an RN and a DM, prior to their hire, as mandated by facility policy. HR staff could not provide documentation of these checks, and the Administrator confirmed that policy was not followed for both direct hires and contracted staff.
The facility did not develop or update baseline care plans within 48 hours of admission for two residents, including one with complex medical needs, and failed to provide a care plan summary to another resident or their representative. Staff interviews revealed confusion about responsibilities and processes for care plan completion and communication, resulting in incomplete documentation and lack of timely care planning.
A medication cart containing various prescription and over-the-counter drugs was left unlocked and unattended in a hallway, accessible to staff and residents, while the responsible LVN was distracted by a family member. The cart was out of the nurse's sight for several minutes, contrary to facility policy requiring medication carts to be locked when not attended by authorized personnel. The DON and ADON confirmed the expectation that carts remain secured at all times.
Two CNAs failed to perform proper hand hygiene and peri-care during incontinent care for a resident with a history of metabolic encephalopathy and cystitis. Neither staff member washed their hands or used sanitizer during or after care, and one reused a wipe before discarding it. The facility's policy requiring handwashing after glove removal and after care was not followed, and the lapse was confirmed in staff interviews.
The facility did not ensure residents received their mail on Saturdays, as reported by seven residents. Mail was only distributed Monday through Friday, with a resident clarifying she did not distribute mail on Saturdays despite claims from the Business Office Manager. The weekend receptionist retrieved Saturday mail, which was then sorted and distributed on Monday. The Administrator was unaware of this issue and confirmed there was no policy for mail distribution.
The facility did not post the HHSC complaint number and statement about filing complaints with the State Survey Agency. During an observation, it was found that this information was missing in the lobby area. A group interview with residents revealed they were unaware of how to contact the agency for complaints. The Administrator was unaware of the missing postings and confirmed the absence of a policy for required postings.
The facility failed to accommodate resident food preferences, specifically regarding the preparation of peanut butter and jelly sandwiches. Residents reported that the jelly was too thick and tore the bread, an issue linked to a change in supplier. Despite ongoing complaints, there was no policy to address these preferences, and the problem persisted for several months.
The facility failed to maintain food safety and hygiene standards in its kitchen. The fryer was left uncovered with grease debris, and sugar and flour containers were not sealed properly. Dietary Aide B did not follow proper hand hygiene during meal preparation, leading to potential cross-contamination. Additionally, containers for icing and broths were found with crumbs and particles, indicating inadequate cleaning. These observations highlight a failure to adhere to the facility's policies on equipment cleaning, food storage, and hand hygiene.
Failure to Follow Menus and Document Substitutions During Meal Service
Penalty
Summary
The facility failed to ensure that menus were followed and that any substitutions were properly documented and communicated to residents during meal service across all four halls reviewed. On the specified lunch service, residents did not receive all food items listed on the menu, specifically macaroni salad, and two residents on pureed diets did not receive the required pureed roll. Observations confirmed that trays were served without the macaroni salad or an immediate substitute, and the pureed roll was omitted for two residents with special dietary needs. Staff interviews revealed that the kitchen did not have macaroni salad available, and residents were not informed of the missing item at the time of meal service. Multiple grievances had been previously logged by residents regarding missing food items, incorrect meals, and incomplete trays, indicating a pattern of similar issues. During the observed lunch, staff acknowledged that substitutions were not offered at the time of meal service, and alternative items such as chips or mashed potatoes were only provided later in the afternoon as a snack, rather than as part of the meal. The dietary manager and dietitian confirmed that all menu items should have been served or substituted with items of equivalent nutritional value, and that documentation of substitutions should occur prior to meal service. However, the substitution log for the day in question was only completed after the meal, and residents were not notified of the changes in a timely manner. One resident with severe protein-calorie malnutrition and dysphagia, who required a mechanically altered diet, did not receive the prescribed pureed roll and reported not having received bread options in the past. Staff interviews indicated confusion and lack of communication regarding menu substitutions and the process for notifying residents. The facility's own policies required that menu changes be documented and reviewed by the dietitian, and that substitutions be of equivalent nutritive value, but these procedures were not followed during the observed meal service.
Failure to Notify Resident Council of Grievance Resolutions
Penalty
Summary
The facility failed to consider and act promptly upon the grievances and recommendations of the Resident Council regarding issues of resident care and life in the facility. Specifically, for multiple grievances raised by the Resident Council in February, March, and August 2025, there was no evidence that the facility provided a verbal or written response to the Council addressing the reported concerns. The grievances included issues with nursing services, dietary services, and housekeeping services. Documentation in the grievance logs often indicated that residents were notified of resolutions through one-to-one discussions, but there was no documentation that the Resident Council as a group was informed of the outcomes, particularly for grievances submitted collectively by the Council. Interviews with residents revealed that none of the nine Resident Council members interviewed had received feedback regarding their grievances from August, and they stated that issues they had reported remained unresolved. Residents also reported that staff rarely attended Council meetings to discuss grievance resolutions, with only occasional attendance by the administrator and dietary manager. The Assistant Director (AD) confirmed that while she took notes and submitted grievances on behalf of the Council, there was no consistent follow-up or communication of resolutions to the Council members. The Social Worker (SW), responsible for handling grievances, stated that she would typically notify the Council president individually but had no documentation of such communication, and acknowledged that resolutions were not routinely shared with the Council as a group. The facility's grievance policy required that grievances be taken seriously, documented, investigated, and that findings and resolutions be communicated to the complainant in a timely manner. However, the policy was not followed in practice, as evidenced by the lack of documentation and communication with the Resident Council regarding the outcomes of their grievances. The administrator and other department heads believed that residents had been informed of resolutions, but resident interviews and record reviews did not support this. The failure to notify the Resident Council of grievance outcomes was attributed to workload issues and lack of a clear process for group communication.
Failure to Maintain Accurate and Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the current needs and interventions for three residents. For one resident with severe cognitive impairment and a stage 4 pressure ulcer, the care plan included an intervention for negative pressure wound therapy, but there was no physician order for this therapy, and staff confirmed the resident was not receiving it. The care plan was not updated to reflect the actual wound care being provided, and the responsible staff indicated that the care plan should not have included this intervention if it was not in use. Another resident with moderate cognitive impairment and on hemodialysis did not have care plan interventions addressing the assessment and monitoring of her condition before and after dialysis treatments. The care plan only included Enhanced Barrier Precautions for the dialysis access device but lacked documentation of ongoing communication and collaboration with the dialysis facility or monitoring for complications related to dialysis. Staff interviews confirmed that dialysis care needs were not addressed in the care plan, and this omission was not identified during interdisciplinary team (IDT) reviews. A third resident, who was dependent on staff for transfers and had a history of sleeping in a recliner, had a care plan that did not accurately reflect her current transfer status or sleeping arrangements. The care plan indicated one-person assistance for transfers, while staff and the resident confirmed that a mechanical lift with two staff was required. Additionally, the care plan listed a full code status, but physician orders and documentation indicated a DNR status. Staff interviews revealed that care plans were not updated to match the resident's current needs and wishes, and there was confusion among staff regarding responsibility for maintaining accurate care plans.
Unqualified Activity Director Leads Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required. Record review showed that the activity director (AD), hired on July 17, 2024, did not have evidence of certification or training as a qualified therapeutic recreation specialist or as an activities professional meeting state licensing requirements. The AD acknowledged during an interview that she had not completed the required course due to financial and time constraints. The job description for the AD position, signed at the time of hire, specified that successful completion of a state-approved and certified course in patient activities was required within nine months of employment. The administrator (ADMN) confirmed awareness that the AD was not certified at the time of hire and stated that the AD was responsible for completing the required courses. The ADMN explained that financial issues delayed the AD's enrollment in the program and that it took additional time for the facility's corporate organization to agree to pay for the course. At the time of the survey, the AD had not yet received the course, and there was no documentation of completed certification or training in the employee file.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to provide meals and snacks at times consistent with residents’ needs, preferences, and posted schedules. On the observed date, lunch was scheduled for 11:45 a.m., but meal service did not begin until after 12:30 p.m., with the last trays being served at 1:32 p.m. Observations showed that food was served late to all areas, including the dining room and all four halls. The DON was observed instructing staff to serve food without a menu item due to the delay, acknowledging the residents were waiting. Nine residents interviewed reported that meals were consistently not served on time and had previously filed grievances about late meal service. Staff interviews revealed a lack of policy regarding meal service timing, with both the DM and DOO stating they were unaware of specific requirements. The dietitian stated her expectation was for all trays to be served within 45 minutes of the posted mealtime but noted that more education was needed for kitchen staff. Review of the facility’s grievance log showed multiple complaints throughout the year regarding late meal service and cold food, indicating an ongoing issue with timely meal delivery.
Failure to Monitor and Document Food Temperatures in Dietary Services
Penalty
Summary
The facility failed to ensure that all food service staff met local, state, and federal requirements regarding food safety, specifically in the areas of food temperature monitoring and documentation. During lunch service, staff pureed hot foods such as kielbasa sausage, green beans, and macaroni salad using cold milk as a thinning agent, resulting in food temperatures below the required threshold. The staff member responsible did not reheat the foods to the appropriate temperature after mechanically altering them and did not take additional temperature readings before serving. The dietary manager (DM) and other dietary leadership confirmed that food temperatures should be taken after preparation and prior to service, and that the use of cold milk could lower food temperatures below safe levels. Additionally, the facility failed to document required food temperatures on the temperature log for multiple meals over several days. There was no evidence that holding temperatures were taken or recorded for numerous breakfasts, lunches, and dinners within the reviewed period. The DM stated that cooks were responsible for obtaining and recording temperatures, and that she monitored compliance, but could not explain missing documentation for certain meals. The contracted dietary operations officer and the facility dietitian both stated that food temperatures should be checked after preparation and again before service, and that foods not at the correct temperature could cause illness. Facility policy and the FDA Food Code require that mechanically altered foods be reheated to at least 165°F for 15 seconds and that hot foods be held at or above 135°F. The policy also mandates that temperatures be taken and recorded prior to meal service. The review of facility records showed repeated failures to meet these requirements, with missing temperature documentation and improper handling of pureed foods, placing residents at risk for foodborne illness as directly stated by staff in the report.
Failure to Complete and Maintain Required Employability Checks for Staff
Penalty
Summary
The facility failed to follow its written policies and procedures designed to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility did not ensure that employability status checks (EMR/NAR) were completed and maintained for two employees, an RN and a dietary manager, prior to their hire dates as required by facility policy. Record reviews revealed that neither employee had documentation of an EMR/NAR check in their personnel files at the time of hire, and the checks were either not performed or not retained as evidence. Interviews with the HR staff confirmed that she was responsible for conducting and maintaining EMR checks but could not provide proof that the checks were completed for the RN and assumed the contracted company handled the check for the dietary manager. The administrator acknowledged that the policy was not followed and that all staff, including contracted employees with resident contact, were required to have EMR checks completed and documented. The lack of adherence to these procedures placed residents at risk of receiving care from individuals who may not have been eligible for employment.
Failure to Develop and Communicate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan or comprehensive care plan with necessary information within 48 hours of admission for two residents. For one resident, the facility used a prior baseline care plan upon readmission and did not update signatures or create a new baseline care plan as required by facility policy. This resident had multiple medical diagnoses, including pneumonia, acute respiratory failure, depression, cognitive communication deficit, and anemia, and had new physician orders upon readmission that were not reflected in an updated baseline care plan. For the other resident, there was no evidence that a summary of the baseline care plan was provided to the resident or their representative. Interviews with facility staff revealed confusion and lack of adherence to policy regarding the creation and updating of baseline care plans, especially in cases of readmission. The admitting nurse and RN on duty were responsible for updating and completing baseline care plans, while the DON was responsible for monitoring signatures. Staff acknowledged that a new baseline care plan should have been started for readmitted residents, and that the failure to do so was not in line with facility policy. There was also a lack of documentation regarding the provision of baseline care plan summaries to residents or their representatives.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart (Cart Hall D) was observed left unlocked and unattended for five minutes while not in use. During this time, three CNAs and residents were present in the hallway within arm's reach of the cart, and the responsible nurse was not in sight. The cart contained various medications, including controlled substances, anti-depressants, blood thinners, anti-diabetics, anti-psychotics, and other medical supplies. The Assistant Director of Nursing (ADON) confirmed that the cart should not have been left unlocked and stated that the responsible nurse, LVN A, was distracted by a family member and followed them down the hall, leaving the cart unsecured. LVN A stated she did not believe she had left the cart unlocked, but acknowledged that leaving medication carts unsecured could negatively affect residents. The Director of Nursing (DON) stated her expectation that all medication carts be locked when out of the nurse's direct vision and confirmed that she periodically checks the carts throughout the day. Facility policy requires that medication carts be locked when not attended by authorized personnel. The failure to secure the medication cart was attributed to poor judgment on the part of the nurse.
Failure to Maintain Infection Control During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper peri-care and hand hygiene practices observed during incontinent care for a resident. During the observation, two CNAs performed peri-care for a female resident with a history of metabolic encephalopathy and cystitis, who was cognitively intact and had a care plan addressing incontinence. Neither CNA washed their hands or used hand sanitizer at any point during the peri-care process, and one CNA was observed folding and reusing a wipe before discarding it, despite the presence of a bowel movement. Interviews with the involved CNA revealed an awareness of the failure to follow proper peri-care and hand hygiene protocols, citing the absence of hand gel in the room as a reason for not performing hand hygiene between glove changes and after care. The CNA acknowledged the potential for cross-contamination and bacterial transfer. The DON confirmed that staff are expected to follow facility policy, which requires handwashing after glove removal and after providing care, and stated that staff are regularly monitored. Facility policy on incontinent care specifically outlines the need for hand hygiene at key points during the procedure, which was not followed in this instance.
Failure to Follow Menus and Document Substitutions During Meal Service
Penalty
Summary
The facility failed to ensure that its menus were followed and that any substitutions were properly documented and communicated to residents. On the date in question, multiple residents did not receive all food items listed on the lunch menu, specifically macaroni salad, and two residents on pureed diets did not receive the required pureed roll. Observations confirmed that trays were served without these items, and staff interviews revealed that the kitchen did not have macaroni salad available and did not inform residents of the missing item or provide an immediate substitute during the meal service. Resident records indicated that at least one resident had significant nutritional needs, including severe protein-calorie malnutrition and dysphagia, requiring a mechanically altered diet. The care plan for this resident specified that the prescribed diet should be followed. Despite this, the resident did not receive the pureed roll as ordered, and staff acknowledged the oversight. The facility's grievance log also documented multiple prior complaints about missing food items, incomplete trays, and lack of communication regarding menu changes. Staff interviews and policy reviews confirmed that substitutions should be of equivalent nutritive value, documented prior to meal service, and communicated to residents. However, the substitution log for the meal in question was completed after the fact, and residents reported that substitutes were only offered later in the afternoon, not during the meal. The dietitian and dietary manager both stated that all menu items should be served as planned or with appropriate substitutions at the time of service, and that failure to do so could impact residents' nutritional intake.
Failure to Notify Resident Council of Grievance Resolutions
Penalty
Summary
The facility failed to consider and act upon the views, grievances, and recommendations of the Resident Council regarding issues of resident care and life in the facility. Specifically, for multiple months, the Resident Council submitted grievances related to nursing, dietary, and housekeeping services, but there was no evidence that the facility provided a verbal or written response to the Council addressing these concerns. Documentation showed that the Social Worker (SW) often marked grievances as resolved through 'one-to-one' discussions, but there was no record of these discussions occurring with the Council or its members, and residents reported not being informed of resolutions. Interviews with residents and staff revealed that the process for addressing Resident Council grievances was inconsistent and lacked follow-up. Residents stated that they rarely received feedback about their grievances, and issues they raised remained unresolved. Staff interviews confirmed that while grievances were documented and distributed to department heads, there was no established process to ensure that resolutions were communicated back to the Resident Council. The SW and Assistant Director (AD) acknowledged that resolutions were not routinely shared with the Council, and there was confusion about who was responsible for this communication. The facility's own grievance policy required that grievances be investigated, documented, and that findings and resolutions be communicated to the person or group who raised the concern. However, the policy was not followed, as there was no documentation of follow-up with the Resident Council, and residents consistently reported a lack of feedback. This failure was observed for all nine Resident Council members reviewed, and included grievances about nursing, dietary, and housekeeping services, as well as issues such as assistance with smoke breaks.
Failure to Maintain Accurate and Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the current needs and interventions for three residents. For one resident with severe cognitive impairment and a stage 4 pressure ulcer, the care plan included negative pressure wound therapy as an intervention, despite there being no physician order or evidence that this therapy was ever provided. Staff interviews confirmed that the resident was not receiving negative pressure therapy, and the care plan was not updated to reflect the actual care being provided. Another resident, who was moderately cognitively impaired and receiving hemodialysis, had a care plan that only addressed enhanced barrier precautions for her vascular access device. The care plan did not include necessary interventions such as assessment and monitoring for complications before and after dialysis, nor did it document ongoing communication with the dialysis facility. Staff interviews revealed that the omission was not identified or corrected during interdisciplinary team (IDT) reviews, and the responsibility for updating the care plan was not clearly followed. A third resident, who was cognitively intact but dependent on staff for transfers and had a DNR order, had a care plan that did not accurately reflect her current transfer needs, sleeping arrangements, or code status. The care plan listed one-person assistance for transfers, while staff confirmed that a mechanical lift with two staff was required. Additionally, the care plan indicated a full code status, while the medical record and physician orders documented DNR status. Staff interviews indicated that these discrepancies were not addressed due to lapses in updating the care plan following changes in the resident's condition and preferences.
Unqualified Activity Director Leads Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by state regulations. Record review showed that the activity director (AD), hired on July 17, 2024, did not have evidence of certification or training as a qualified therapeutic recreation specialist or as an activities professional meeting state licensing requirements. The AD's job description required successful completion of a state-approved and certified course in patient activities within nine months of employment, but there was no documentation that this had been achieved. Interviews revealed that the AD experienced difficulties enrolling in the required course due to financial and time constraints. The administrator (ADMN) acknowledged awareness of the AD's lack of certification at the time of hire and stated that the AD was responsible for completing the necessary courses. The ADMN further explained that financial issues delayed the AD's enrollment, and it took additional time for the facility's corporate organization to agree to pay for the course. At the time of the survey, the AD had not yet received the required training or certification.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to provide meals and snacks at times consistent with residents’ needs, preferences, and posted schedules. On the observed date, lunch was scheduled for 11:45 a.m., but meal service did not begin until after 12:30 p.m., with the last trays being served at 1:32 p.m. Observations showed that food was served late to all areas, including the dining room and all four halls. The DON was observed instructing staff to serve food without a menu item due to the delay, acknowledging the residents were waiting. Nine residents interviewed reported that meals were consistently late and had previously filed grievances about the issue. Staff interviews revealed a lack of policy regarding meal service timing, with both the DM and DOO stating they were unaware of specific requirements. The dietitian expected trays to be served within 45 minutes of the posted mealtime but noted that more education was needed for kitchen staff. Review of the facility’s grievance log showed multiple complaints throughout the year regarding late meal service and cold food, indicating an ongoing issue with timely meal delivery.
Failure to Monitor and Document Food Temperatures in Dietary Services
Penalty
Summary
The facility failed to ensure that all food service staff met local, state, and federal requirements regarding food safety, specifically in the areas of food temperature monitoring and documentation. During lunch service, staff pureed hot foods using cold milk as a thinning agent and did not reheat the foods to the required temperature of 165°F after mechanical alteration. Temperature readings taken immediately after pureeing showed the foods were below the required temperature, and no further temperature checks were performed before the food was plated and served. The staff member responsible stated she believed the steam table would bring the food to the correct temperature and did not take additional steps to ensure compliance. Interviews with the Dietary Manager (DM), Director of Operations (DOO) for contracted dietary staff, and the dietitian revealed inconsistent understanding and implementation of food temperature protocols. The DM acknowledged that food should be heated to above 165°F for hot foods and below 40°F for cold foods after preparation, but did not require temperatures to be retaken before service if initial readings were appropriate. The DOO and dietitian both stated that food temperatures should be checked after preparation and again prior to service, and that the steam table was not suitable for reheating food. The dietitian also noted that adding cold milk to hot foods could lower the temperature below safe levels, increasing the risk of foodborne illness. A review of the facility's Food Temperature and Evaluation Log for multiple meals over several days showed missing documentation of required food temperatures, with no evidence that holding temperatures were taken for numerous meals. Facility policy and FDA Food Code require that mechanically altered foods be reheated to 165°F for 15 seconds and that hot holding temperatures remain at or above 135°F, with corrective action if temperatures fall below this threshold. The lack of adherence to these protocols and incomplete documentation placed residents at risk for foodborne illness, as directly stated by staff in the report.
Failure to Complete and Maintain Required Employability Status Checks for Staff
Penalty
Summary
The facility failed to follow its written policies and procedures designed to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility did not ensure that required Employability Status Checks (EMR/NAR) were completed and maintained for two employees, an RN and a Dietary Manager (DM), prior to their hire dates. Record reviews revealed that neither employee had documentation of an EMR/NAR check in their files as required by facility policy, which mandates that all team members, regardless of position, must have this verification completed before employment. Interviews with the HR staff confirmed that she was responsible for running and maintaining EMR checks but could not provide evidence that the checks were completed for the RN and DM before their hire. The HR stated that she may have run the check for the RN but could not locate the documentation, and for the DM, she assumed the contracted company handled the check, but no proof was available. The Administrator acknowledged that the policy was not followed and that all staff, including contracted employees with resident contact, should have had EMR checks completed and maintained in their files.
Failure to Complete and Communicate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, as required by policy. For one resident, the baseline care plan used upon readmission was not updated, and there was no evidence of updated signatures after the readmission. This resident had multiple medical diagnoses, including pneumonia, acute respiratory failure, depression, cognitive communication deficit, and anemia, and required specific treatments such as anticoagulant monitoring, anticonvulsant and antidepressant medications, and CPAP at night. The facility did not initiate a new baseline care plan or complete all new admission paperwork as required for a readmission, and the care plan was not updated to reflect the resident's current needs and orders. For another resident, there was no evidence that a summary of the baseline care plan was provided to the resident or their representative. Interviews with facility staff revealed confusion regarding responsibilities for updating and signing baseline care plans, as well as a lack of clarity about the process for residents who are readmitted. The facility's policy requires that baseline care plans be developed and implemented within 48 hours of admission and that summaries be provided to residents or their representatives, but these steps were not completed for the two residents reviewed.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on Hall D was observed to be left unlocked and unattended for approximately five minutes while not in use. During this time, three CNAs and residents were present in the hallway within arm's reach of the cart, and the responsible nurse was not in sight. The cart contained various medications, including anti-depressants, blood thinners, anti-hypertensives, diuretics, insulin pens, anti-psychotics, anti-anxiety medications, creams, syringes, liquid medications, alcohol pads, and over-the-counter medications. The Assistant Director of Nursing (ADON) confirmed that the cart should not have been left unlocked and unattended, and the Director of Nursing (DON) stated that her expectation is for all medication carts to be locked when out of direct vision of the nurse. The nurse responsible for the cart reported being distracted by an upset family member and followed them down the hall, leaving the cart unsecured. The facility's policy requires that medication carts be locked when not attended by authorized personnel. The DON acknowledged that the failure occurred due to poor judgment on the nurse's part and confirmed that she periodically checks to ensure medication carts are locked throughout the day.
Failure to Maintain Infection Control During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during incontinent care for a female resident with a history of metabolic encephalopathy and cystitis. During peri-care, neither CNA performed hand hygiene at any point, including after removing soiled gloves and after completing care, despite the presence of a bowel movement. One CNA was observed folding and reusing a wipe before discarding it. Both CNAs failed to follow the facility's policy, which requires handwashing after glove removal and after providing care. Interviews confirmed that the CNA was aware of the failure to perform proper peri-care and hand hygiene, attributing the lapse to not having hand sanitizer in the room. The CNA had received infection control and peri-care training three months prior. The DON acknowledged that staff should have followed policy and that the facility regularly monitors staff, but suggested the CNA's performance may have been affected by being observed by surveyors. The facility's policy on incontinent care clearly outlines the required steps for hand hygiene and glove use, which were not followed during the observed incident.
Failure to Distribute Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents' right to receive their mail on Saturdays, affecting seven residents who were interviewed. During a group interview, all seven residents reported that mail was only delivered Monday through Friday, coinciding with the business office's operating hours, and not on weekends. The Business Office Manager claimed that a resident volunteered to distribute mail on Saturdays, but this resident clarified that she did not distribute mail on Saturdays and waited until Monday to do so. The weekend receptionist retrieved the mail on Saturdays and took it to the business office, where it was sorted and then given to the resident for distribution on Monday. The Administrator was unaware of the issue and acknowledged the absence of a policy regarding mail distribution.
Failure to Post HHSC Complaint Information
Penalty
Summary
The facility failed to post the Health and Human Services Commission (HHSC) complaint number and a statement informing residents of their right to file a complaint with the State Survey Agency. This deficiency was identified during an observation of the facility's front lobby area, where it was noted that the required information was not displayed. Additionally, a confidential group interview with seven residents revealed that they were unaware of how to contact the State Survey Agency to file complaints. The facility's Administrator admitted to not knowing why the postings were absent and acknowledged the importance of having such information available to residents. Furthermore, the Administrator confirmed that there was no existing policy regarding the required postings.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their preferences, specifically regarding the preparation of peanut butter and jelly sandwiches. During a confidential group interview, seven residents expressed dissatisfaction with the way peanut butter and jelly were served, noting that the jelly was too thick and tore the bread when spread. This issue was attributed to a change in the jelly supplier to Company D, which provided a thicker jelly. The Dietary Manager acknowledged the residents' complaints about the jelly's thickness during monthly Food Committee meetings but noted the absence of a policy regarding resident preferences. The Consultant Dietitian confirmed that the Administrator had purchased jelly from a local store to address the residents' preferences temporarily. However, there was no specific policy in place to address food preferences, and the alternate list provided still included the problematic peanut butter and jelly option. The Resident Food Committee Meeting Minutes from April also reflected concerns about the jelly, indicating that the issue had been ongoing for several months without resolution.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The fryer was found uncovered with dark oil and grease debris, and the dietary staff was unsure of its last use. The fryer was supposed to be cleaned and have its oil replaced weekly, but it was not covered, which could lead to contamination. Additionally, the sugar and flour containers in dry storage were not sealed properly, with white particles observed on the lids, indicating a lack of cleanliness and potential for contamination. During meal preparation, Dietary Aide B did not practice proper hand hygiene. The aide was observed touching various surfaces and food items without washing hands between glove changes, which is against the facility's policy. This lapse in hygiene practices could lead to cross-contamination, as acknowledged by the Dietary Manager. The aide was working on a prn basis and had recently returned to the kitchen, which may have contributed to the oversight in following proper procedures. Further observations revealed that containers for icing, chicken broth, and beef broth had crumbs and particles on them, suggesting inadequate cleaning practices. The Dietary Manager was unsure of the source of the contamination but acknowledged that the containers should be clean. The facility's policies on equipment cleaning, dry food storage, and hand hygiene were not followed, as evidenced by the conditions observed in the kitchen.
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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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