Greenview Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Waco, Texas.
- Location
- 401 Owen Ln, Waco, Texas 76710
- CMS Provider Number
- 455638
- Inspections on file
- 52
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Greenview Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with ESRD, chronic musculoskeletal conditions, and prior left shoulder dislocation was transported to and from dialysis in a facility van using a manual wheelchair. During the return trip, the wheelchair was anchored to the van floor, but the resident was not secured with a seat belt or cross belt. When the driver braked at an intersection, the resident slid out of the wheelchair onto the van floor and remained there until arrival back at the facility. Nursing documentation and imaging later confirmed an acute fracture of the right third metatarsal and shoulder pain associated with a chronic left shoulder dislocation. Facility policy and federal ADA transportation specifications required that wheelchair users be secured with both wheelchair tie‑downs and a passenger seat belt/shoulder harness, but interviews and record review showed that the resident was not properly restrained, leading to the accident and injury.
The facility failed to provide immediate access to residents and records for an HHSC surveyor conducting a Priority One investigation, when the ADM refused entry and the surveyor was instructed to leave, causing a four-hour delay before the entrance conference and investigation began. The ADM later acknowledged acting between corporate staff and HHSC and reported there was no facility policy addressing impeding surveys or access to medical records. At the time, there were 93 residents in the facility, and governing body policy and state regulations required allowing HHSC representatives to enter and conduct necessary inspections and investigations.
Surveyors found multiple improperly stored food items in the kitchen, including unsealed dry goods, unlabeled and undated containers of white granulated substances, uncovered and unlabeled fruit cups in Styrofoam cups in the refrigerator, an unsealed bag of shredded cheese, and an unsealed bag of frozen cookie dough in an opened box in the freezer. The DM and dietary staff acknowledged that all staff had been trained on proper food storage, including sealing, labeling, dating, and first-in/first-out rotation, and recognized that items had been left open or without required date marking. Facility policies required dry foods in bins to be labeled and dated, and all refrigerated and frozen foods to be covered, labeled, and dated, with the person opening or preparing food responsible for date marking, but these procedures were not consistently followed.
Surveyors found that a room’s call light system was non-functioning and pulled out of the wall, while two residents with mobility limitations, fall history, and cognitive and physical impairments were left without reliable, accessible means to summon staff. One resident, cognitively intact but dependent for toilet transfers and with osteoarthritis, COPD, neuropathy, and prior falls, had a non-working call light placed within reach and a bell placed out of reach, and reported using the bathroom call button solely to get help. Another resident with dementia, repeated falls, muscle weakness, and abnormal gait had a non-functioning call light within reach and reported sometimes yelling for help. The Maintenance Director, DON, and Administrator acknowledged awareness of the broken call system and the use of bells as interim measures, while facility maintenance records documented ongoing call light problems in that room over several months.
Two residents shared a room where the wall-mounted call light system was non-functional and pulled out of the wall, yet the inoperative call buttons were still placed within reach as if usable. One resident reported the call system had been broken for months and that the alternative bell provided was out of reach, requiring the resident to go to the bathroom to use the call button there when needing assistance. The Maintenance Director, DON, and Administrator all acknowledged awareness of the broken call system, and maintenance records documented a malfunctioning and later completely broken call light, despite facility policies requiring a safe, accommodating environment.
A resident with COPD, muscle weakness, Type 2 DM with complications, and prior cerebral infarction had an admission MDS showing moderate cognitive impairment and total dependence for chair/bed-to-chair transfers requiring assistance of two or more helpers. Although the CNA Kardex indicated a two-person transfer and the resident was care planned for pressure injury risk related to decreased mobility, the comprehensive care plan did not address ADLs or specify the mode of transfer, and there was no physician order for mechanical lift use. The DON stated that mechanical lift use should be supported by a physician order and reflected in the care plan, and the MDS nurse acknowledged she had overlooked care planning the mechanical lift transfer despite facility policy requiring all identified needs from the MDS and CAAs to be incorporated into a person-centered care plan with measurable objectives and timeframes.
A resident with COPD, muscle weakness, Type 2 DM with complications, a history of cerebral infarction, and moderate cognitive impairment was documented on the MDS and CNA Kardex as dependent for chair/bed-to-chair transfers requiring two-person assistance. The resident’s care plan addressed pressure injury risk but did not include ADLs or transfer method. Despite facility policies and training requiring two staff for mechanical lift transfers, a CNA, who knew two staff were required, independently transferred the resident using a mechanical lift because another CNA was busy and the resident was urging to be gotten up quickly, resulting in a failure to provide adequate supervision and assistance during the transfer.
Dietary staff did not label or date food items in the refrigerator and freezer, and kitchen air conditioning vents were found with a black substance. Staff interviews revealed confusion about responsibilities for labeling food and cleaning vents, despite facility policies requiring these practices.
A resident's personal refrigerator was found with a brown substance, a food-encrusted butter knife, and lacked a temperature log. Staff interviews confirmed that required weekly cleaning and temperature checks were not performed, despite facility policy assigning these responsibilities to maintenance and housekeeping.
A resident with dementia and a history of frequent physical aggression was not provided with continuous 1:1 supervision as previously recommended by the psychiatric provider, despite repeated altercations with another resident. The decision to discontinue close monitoring was made by the IDT without input from the psychiatric nurse practitioner, and staff interviews confirmed ongoing aggressive behaviors and concerns about resident safety.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
A resident with dementia and a high risk of elopement exited a secure unit unsupervised after the assigned RN left to respond to a code and the only CNA was on break. The resident was able to leave through a door that did not latch properly, walked through the building, exited a side door, and entered a parked fire truck without staff present. Staff interviews revealed unclear protocols for code response and supervision, and a lack of recent in-service training on elopement prevention.
A resident with spastic quadriplegic cerebral palsy developed a wound on his right calf from wheelchair friction, but did not receive weekly skin assessments, timely wound care orders, or a therapy consult as required. The wound was not properly monitored or treated for several weeks, leading to deterioration. Staff interviews revealed lapses in wound care processes and documentation, and the facility's policy for regular skin assessments was not followed.
A resident with Parkinson's Disease and other chronic conditions did not receive prescribed doses of Rytary (Carbidopa-Levodopa) within the required one-hour window on multiple occasions. The resident experienced increased tremors and slurred speech due to these delays. Interviews with the DON and MD confirmed awareness of the issue, which was attributed to agency nurse unfamiliarity and staffing challenges. Facility policy required timely administration, but this standard was not met.
The facility did not maintain a sanitary kitchen environment, as multiple dead cockroaches and food debris were observed in key kitchen areas, including the entryway, under storage racks, and around the ice machine. Staff interviews revealed inconsistent cleaning practices, lack of cleaning logs, and insufficient staffing, all contributing to unsanitary conditions in violation of the facility's sanitation policy.
A CNA was observed serving and assisting residents with their meals without performing hand hygiene between each tray passed. The CNA admitted to not following hand hygiene protocols despite prior training. Both the DON and ADM confirmed that staff are expected to sanitize hands before and between passing trays, in accordance with facility policy, to prevent cross contamination and infection.
A resident with severe cognitive impairment, legal blindness, and muscle weakness was found twice with his call light out of reach, making it inaccessible for requesting assistance. Staff interviews confirmed it was their responsibility to ensure call lights were within reach, but they were unaware of the issue. Facility policy required call lights to be accessible and secured for each resident, but this was not followed in this case.
The facility did not report an allegation of resident-to-resident physical abuse to the State Survey Agency within the required 24-hour timeframe. Two residents, one with moderate cognitive impairment and another cognitively intact, were involved in a hallway altercation where one pushed or hit the other in the chest. The incident was reported internally but not to authorities until several days later, as the ADM delayed reporting while investigating conflicting accounts.
The facility failed to maintain food safety and hand hygiene standards, with observations revealing improperly labeled and dated food, unsanitary kitchen conditions, and staff neglecting to take food temperatures. Additionally, an LVN and a CNA did not practice proper hand hygiene while distributing food, increasing the risk of cross-contamination and infection spread.
The facility failed to provide a private space for resident meetings, using a dining room with inadequate curtains for privacy. Residents reported unresolved grievances about food quality and missing clothing, with no follow-up from staff. The facility lacked a social worker to handle grievances, leading to ineffective communication and resolution.
The facility failed to provide a safe, sanitary, and comfortable environment for residents, as observed in multiple rooms with unclean and disrepaired conditions. Residents' rooms and bathrooms were found with dust, dirt, mold, and unemptied trash, while maintenance issues like leaking toilets were unresolved. Interviews with staff revealed inconsistencies in following cleaning schedules and maintenance protocols, contributing to the deficiencies.
Two residents in a facility were found without access to their call lights, compromising their ability to request assistance. One resident, with moderate cognitive impairment and multiple health conditions, had her call light out of reach on the floor. Another resident, with severe cognitive impairment, was left in the middle of the room without a call light, unable to remove his sweater and unattended for nearly 10 minutes. Staff interviews confirmed that these situations were not typical or acceptable, highlighting a failure to adhere to facility policies on call light accessibility.
A privacy breach occurred when an RN left a laptop open and unattended in a hallway, displaying a resident's medical information during wound care. The resident, who was severely cognitively impaired, had multiple medical conditions. Despite training on privacy and HIPAA regulations, the RN admitted to inadvertently leaving the laptop open, violating the facility's policy on resident rights.
A facility failed to obtain necessary hospice documentation for a resident admitted to hospice care, including the hospice plan of care, physician orders, and contact information for hospice personnel. This lack of documentation could lead to confusion about the resident's care and services provided.
A resident with severe cognitive impairment due to dementia was involved in two unreported resident-on-resident abuse incidents. The first incident involved physical assault on a roommate, which was not reported to the state office due to a lack of perceived threat and no documented injuries. The second incident involved the same resident using a wheelchair to abuse another roommate, which was reported. Staff interviews revealed inconsistencies in reporting procedures, highlighting a failure to adhere to the facility's policies on abuse and neglect.
A resident with severe cognitive impairment and a history of aggressive behavior was involved in multiple altercations with roommates. The facility failed to update the resident's care plan after an initial incident, leaving other residents at risk. Despite staff opinions that the incident should have been reported as abuse, the administration did not perceive the resident as a threat. This inaction led to a subsequent altercation, highlighting the need for timely care plan updates and reporting.
A resident with severe cognitive impairment hit his roommate, leading to a bruise on the roommate's arm. The incident was not reported to the state office within the required two-hour timeframe, and no follow-up investigation was conducted. The facility's administrator decided not to report the incident, citing the absence of injuries and the belief that the resident was not a threat to others.
The facility failed to accommodate residents' needs by not ensuring a functional phone system, leading to missed calls from family and providers. Staff and family members reported ongoing issues with calls disconnecting or going unanswered, particularly on weekends. The problem persisted despite previous attempts to fix it, and staff had to use personal cell phones to maintain communication. The facility's policy on resident rights was compromised due to these phone system issues.
The facility failed to provide scheduled showers and document refusals for two residents with impaired cognition and physical functioning. Despite being scheduled for regular showers, the residents received fewer than expected, with no documentation of refusals or negotiation of ADL times. Staff interviews revealed an expectation to document refusals and educate residents, but this was not consistently done, potentially affecting residents' hygiene and dignity.
The facility failed to maintain proper infection control practices as MAs did not sanitize a wrist blood pressure monitor between uses on multiple residents. This oversight involved residents with conditions like hypertension and diabetes, increasing their risk of infection. Despite training, one MA misunderstood the importance of sanitizing equipment between residents, believing end-of-shift cleaning was sufficient. The DON acknowledged the deficiency and noted the lack of recent specific training on equipment disinfection.
A resident with end-stage renal disease frequently refused hemodialysis (HD) treatments, and the facility failed to update the care plan to reflect this behavior or notify the kidney center (KC) as required. Despite the resident's awareness of the importance of HD, he missed several appointments, leading to hospitalization. Facility staff acknowledged the lack of communication with the KC and the absence of interventions in the care plan.
A resident with dementia and Parkinson's disease was admitted to a facility for respite care and later hospitalized with severe dehydration and rhabdomyolysis. The facility failed to notify the resident's physician or representative about the resident's declining condition and did not address nutritional or hydration needs. The care plan lacked interventions for fluid intake, and the facility did not track fluid intake or document supplemental shake consumption. The resident had not eaten or drunk anything for three days, leading to hospitalization.
A resident with dementia and Parkinson's disease was hospitalized due to severe dehydration and rhabdomyolysis after the facility failed to monitor and address his nutritional and hydration needs. The resident's care plan lacked interventions for these needs, and there was no physician's order for diet or fluid intake. Despite decreased meal intake and known swallowing issues, the facility did not adequately document or provide necessary interventions, leading to the resident's decline and subsequent hospice care placement.
The facility failed to report a resident's fall and a resident-on-resident abuse incident in a timely manner. The fall resulted in a facial injury and the resident's subsequent death, while the abuse incident involved one resident attempting to grab another's pants. Both incidents were not reported to the state agency as required by the facility's policy.
A resident with multiple diagnoses fell and was found on the floor by EMTs. The facility failed to investigate and report the incident within the required five working days. The DON and AD acknowledged gaps in communication and understanding, leading to the failure to follow the facility's policy on investigating and reporting allegations of abuse and neglect.
The facility failed to store, label, and sanitize food products and kitchen equipment according to professional standards, risking resident health. Observations showed improperly sealed and unlabeled food items, unsanitary kitchen equipment, and inadequate staff training. Interviews with staff revealed a lack of adherence to food safety protocols and insufficient oversight by the IDT.
Resident Injured After Being Transported Without Proper Wheelchair Restraint in Facility Van
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly secured during transport in the facility van, resulting in the resident sliding out of a manual wheelchair onto the vehicle floor and sustaining injuries. The resident was an older female with multiple diagnoses including end stage renal disease, abnormal bone density, prior left shoulder dislocation, chronic pain, osteoarthritis, and a nondisplaced fracture of the right third metatarsal. Her MDS showed intact cognition (BIMS 13), dependence for transfers, and use of a motorized wheelchair, with a manual wheelchair used for certain transports. On the day of the incident, she was transported to and from dialysis by the facility’s primary driver in the facility van, using a manual wheelchair because her motorized wheelchair could not be accommodated. According to the resident’s statements and facility interviews, the driver anchored the wheelchair to the van floor using the manual floor anchors but did not secure the resident with a seat belt or cross belt. The resident reported that during the return trip from dialysis she slid completely out of the wheelchair onto the van floor and remained there until arrival back at the facility. The driver stated she had strapped all four buckles to the wheelchair and, when approaching an intersection and braking as the light changed, heard the resident say she was slipping; she reported reaching back to try to prevent further slipping but the resident slid off the mechanical lift pad and landed on her bottom. The administrator and facility driver (maintenance) both indicated that the wheelchair had been anchored but the cross belt or safety belt securing the resident was not used or not properly engaged, despite the van being equipped with safety straps, anchors, and a passenger seat belt and shoulder harness for wheelchair users as required by facility policy and federal ADA transportation specifications. The incident was documented as an unwitnessed fall occurring in the facility van, with the resident found sitting on the van floor and the wheelchair behind her when the vehicle arrived back at the facility. Initial nursing assessment documented no visible injuries, but the resident complained of right leg pain and later generalized pain with a pain score of 6. X‑rays obtained after the incident showed an acute fracture in the neck of the right third metatarsal, and the resident subsequently complained of left shoulder pain, with imaging later identifying a chronic dislocation of the left shoulder. The facility’s policies required that each resident transported in the van be secured in a seat with a seatbelt or in a wheelchair secured with tie‑downs, and that staff authorized to drive the van have necessary training and knowledge of van safety features. Surveyor review of personnel and training records showed that only the two designated transport staff had recently received in‑service education on transporting residents, that the primary driver had a prior transportation skills checklist on file, and that another authorized staff member’s file lacked a transportation skills checklist, while some historical driver safety records were missing after a change in maintenance leadership. These findings, combined with the resident’s account and staff interviews, supported that the resident was not properly secured with a seat belt during transport, leading to the fall from the wheelchair and resulting injuries.
Failure to Provide Immediate Access for Priority One State Investigation
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate access to residents for a state representative of HHSC conducting a Priority One (P1) investigation. On 03/03/2026 at 10:05 a.m., an HHSC surveyor entered the facility, checked in at the reception desk, and was taken to the conference room. At 10:11 a.m., the administrator entered the conference room and informed the surveyor that she would not be allowed into the building to conduct the P1 investigation, even after being advised that it was a P1 investigation. At 10:43 a.m., the surveyor was instructed by phone from the program manager to leave the facility. The program manager then contacted the associate regional director and briefed her on the incident. The surveyor was not allowed to re-enter and begin the entrance conference and P1 investigation until 2:00 p.m., resulting in a four-hour delay in surveyor access. During an interview on 03/03/2026 at 2:00 p.m., the administrator apologized for the situation and stated he was acting like a “ping pong ball” between corporate staff and HHSC. In a subsequent interview on 03/05/2026 at 12:30 p.m., the administrator stated the facility did not have a policy on impeding a survey or access to medical records. Review of the facility census showed there were 93 residents at the time. Review of the facility’s governing body policy indicated the governing body is responsible for establishing and implementing policies regarding management and operation of the facility. Review of state law (Health and Safety Code Ch. 242.043) and HHSC Provider Letter PL 18-26 confirmed that HHSC or its representatives may enter an institution at reasonable times to conduct inspections, surveys, or investigations and that providers must grant access to records, underscoring that the administrator’s refusal and the resulting delay were contrary to these requirements.
Improper Food Storage and Labeling Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, where multiple food items were not labeled, dated, sealed, or stored in accordance with facility policy and professional standards. During a kitchen observation, surveyors found a clear plastic container with a white granulated substance lying on the pantry floor with its lid off and the contents spilled, an unsealed zip bag of pasta, an unsealed bag of tortilla chips, an open box containing an unsealed bag of rice, and an unsealed, unlabeled, and undated plastic tote of a white granulated substance on pantry shelves. In the refrigerator, they observed an unsealed zip bag of yellow shredded cheese and more than a dozen uncovered, unlabeled, and undated Styrofoam cups containing a fruit substance. In the chest freezer, they found an opened box with an unsealed bag of frozen cookie dough. These conditions were inconsistent with the facility’s written policies requiring dry foods in bins to be removed from original packaging, labeled, dated, and rotated using first-in/first-out, and requiring all refrigerated and frozen foods to be covered, labeled, and dated. During interviews, the Dietary Manager (DM) acknowledged the opened items in the pantry and stated that all dietary staff were responsible for ensuring food was stored correctly, but also indicated he often corrected improperly stored food himself without always addressing it with the responsible staff. A dietary staff member reported he had been trained on proper food storage and rotation, including use of zip bags and labeling and dating, and stated he had seen the sugar tub with the lid off and would close it or notify the DM. Another dietary staff member confirmed she had been trained on proper storage, acknowledged the open shredded cheese should have been sealed, and stated that all dietary staff were supposed to store food properly. The Administrator stated his expectation that all food be stored properly and that it was the DM’s responsibility to ensure staff knew and followed the process. Facility policies on Food Receiving and Storage and Date Marking for Food Safety specified that foods must be stored in compliance with safe food handling practices, including covering, labeling, and dating, and that the individual opening or preparing food is responsible for date marking at the time of opening or preparation.
Failure to Provide Accessible Call Systems and Alternatives for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences for calling staff, specifically by not ensuring functioning call systems or accessible alternative devices for two residents. Surveyors observed that the call light system in a shared room was not functioning and the entire call light box was out of the wall. Despite this, the non-functioning call buttons were still placed within reach for both residents. For one resident, a bell intended as an alternative call device was placed on the nightstand but out of the resident’s reach, and there was no visible bell available for the other resident. One resident was an older female with osteoarthritis of the right shoulder and knee, COPD, muscle weakness, joint pain, a history of falls, poor balance, unsteady gait, and impaired physical functioning. Her MDS showed a BIMS score of 15 (no cognitive impairment), partial/moderate assistance needed for bed-to-chair transfers, and total dependence for toilet transfers. Her care plan documented pain related to impaired mobility and neuropathy, as well as an actual fall and impaired physical functioning. During interview, she reported that her room call system had been broken for about six months, that she could not reach the bell on the nightstand, and that when she needed help she would go into the bathroom and use the bathroom call button, even though she did not use the toilet there. The second resident was an older female with repeated falls, muscle weakness, lack of coordination, abnormal gait and mobility, and a need for assistance with personal care. Her MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and her care plan noted impaired cognitive function/dementia, difficulty making decisions, impaired decision making, psychotropic drug use, and impaired physical functioning. She stated she did have a bell to call for help but sometimes yelled for assistance. The Maintenance Director reported the room call system had broken sometime the prior week and that he had ordered a replacement part and provided bells to both residents, and he stated he verbally informed staff of the broken system. The DON and Administrator both acknowledged awareness of the broken call system and that bells were to be used and kept within reach, and facility TELS work orders and an invoice documented call light malfunction and a completely broken call light station in that room over the preceding months.
Failure to Maintain Functional Call System in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident rooms were adequately equipped with a properly functioning call system that relayed calls directly to staff or a centralized work area. Surveyor observation on 01/29/2026 with the Maintenance Director showed that the call light system in the shared room of Resident #2 and Resident #3 was not functioning and the entire call light box was out of the wall. In Resident #2’s area, the non-functioning call button was placed on the bed within reach, and a bell intended as an alternative was on the nightstand but out of reach. In Resident #3’s area, the non-functioning call light was also placed within reach despite not working. The report states this failure placed residents at risk of being unable to obtain assistance for ADLs or in an emergency. During interviews, the Maintenance Director stated the call system in that room had broken sometime the previous week, that he had ordered a replacement part, and that he had provided bells to both residents and verbally informed staff of the problem. However, Resident #2 reported that her call system had been broken for about six months and that she could not reach the bell on the nightstand, so she went to the restroom and used the bathroom call button when she needed help. The DON and the Administrator both acknowledged awareness of the broken call system in that room; the DON was unsure how long it had been broken, while the Administrator estimated it had been broken for a couple of months. Review of the facility’s TELS work orders showed entries for a malfunctioning call light that was unscrewed and unplugged from the wall and, later, a call light completely broken out of the wall and separated from wiring, as well as an invoice for a replacement bedside patient station. Facility policies on Accommodation of Needs and Safe and Homelike Environment required the facility to provide a safe environment and make reasonable accommodations in residents’ physical environment, including bedrooms and bathrooms.
Failure to Care Plan and Obtain Order for Mechanical Lift Transfers
Penalty
Summary
Surveyors identified a failure to develop and implement a person-centered, comprehensive care plan that included measurable objectives and timeframes for a resident’s identified needs, specifically related to transfers. The resident was an older female admitted with COPD, muscle weakness, unspecified pain, Type 2 DM with complications, and a history of cerebral infarction. Her admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and Section GG documented a score of 1 for chair/bed-to-chair transfer, meaning she was dependent and required the assistance of two or more helpers for transfers. Despite these documented needs, the resident’s care plan initiated on 10/25/2025 addressed risk for pressure injury related to decreased bed mobility/transfers, incontinence, poor nutrition, history of skin breakdown, fragile skin, Braden risk score, and sensory perception, but did not address ADLs or specify the means of transfer. The CNA Kardex, printed on 01/29/2026, indicated that the resident required a two-person assist for chair/bed-to-chair transfers, but this information was not reflected in the comprehensive care plan. Additionally, review of the physician orders showed there was no order for transfer via mechanical lift, even though the resident required this level of assistance. During interviews, the DON stated that if a resident required a mechanical lift transfer, there should be a physician order, and that staff would learn of this need through shift report and the CNA Kardex. The DON acknowledged there was a safety issue when a resident was not care planned for mechanical lift transfer and there was no corresponding order. The MDS nurse, who was responsible for completing care plans, stated that the resident’s mechanical lift transfer should have been care planned and that she must have overlooked it, despite the MDS documenting that the resident was dependent for transfers. The facility’s own comprehensive care plan policy required development of a person-centered care plan within 7 days of the comprehensive MDS, inclusion of all triggered CAAs, and measurable objectives and timeframes to meet identified needs, but these requirements were not met for this resident’s transfer needs.
Failure to Use Two-Person Mechanical Lift Transfer as Required
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance devices during a mechanical lift transfer for one resident. The resident was an older female with COPD, muscle weakness, unspecified pain, Type 2 DM with complications, and a history of cerebral infarction. Her admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and Section GG documented that she was dependent for chair/bed-to-chair transfers, requiring the assistance of two or more helpers. Her care plan, initiated earlier, addressed risk for pressure injury related to decreased mobility, incontinence, poor nutrition, history of skin breakdown, fragile skin, Braden risk score, and sensory perception, but did not address ADLs or means of transfer. On the day of the incident, the CNA Kardex for this resident indicated that her chair/bed-to-chair transfer required two persons. Despite this, a CNA was observed transferring the resident alone from bed to chair using a mechanical lift, with no other staff present. The DON, upon arriving at the scene, stated that two people were needed for mechanical transfers. In an interview, the CNA acknowledged she had been trained that two staff were required for mechanical lift transfers for the safety of residents and staff, but reported she proceeded alone because the other CNA on the hall was busy and the resident, who was her family member, was urging her to get her up quickly. Interviews and record review showed that the facility had established policies and training requiring two staff for mechanical lift transfers. The DON stated that staff were informed of residents’ mechanical lift needs during shift report and that CNAs used the Kardex to identify transfer requirements. The MDS nurse stated she was responsible for care plans and that the resident’s need for mechanical lift transfer should have been care planned but was overlooked, even though the MDS documented the resident as dependent for transfers. Facility policies on mechanical lifts, safe resident handling/transfers, and accident and supervision all required two staff for mechanical lift transfers and emphasized safe handling based on the resident’s individual plan of care and assessed needs, but in this case the resident’s transfer method was not included in the care plan and the transfer was performed by a single CNA contrary to policy and documented requirements.
Failure to Label Food and Maintain Clean Kitchen Vents
Penalty
Summary
Dietary staff failed to properly label and date food items stored in the walk-in refrigerator and freezer, as observed during a kitchen tour. Items such as ravioli, hash browns, and pancakes were found in clear plastic bags without any labels or dates. Multiple staff interviews confirmed that all items should be sealed, labeled, and dated, but there was confusion among staff regarding who was responsible for this task. The facility's own Food Receiving and Storage policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated. Additionally, the kitchen's air conditioning vents were observed to be visibly soiled with a black substance, which some staff identified as possible mold or dust buildup. Staff interviews revealed a lack of awareness and uncertainty about who was responsible for cleaning the vents. The facility's Sanitization policy states that kitchen surfaces not in contact with food should be cleaned regularly to prevent grime accumulation. No interviews could be conducted with the Dietary Manager due to illness, and both the Maintenance Director and other staff were unaware of the issue prior to the survey.
Failure to Maintain Sanitary Resident Refrigerator and Temperature Monitoring
Penalty
Summary
The facility failed to maintain a policy regarding the use and storage of foods brought in by family and visitors for residents, specifically for one resident who was reviewed for food and nutrition services. During observation and interview, it was found that the resident's personal refrigerator contained a brown substance stuck to the bottom of both the refrigerator and freezer compartments, as well as a food-encrusted butter knife. There was no temperature log present for the refrigerator, and the resident reported that staff did not clean her refrigerator, although she occasionally stored food in it. Interviews with facility staff revealed that both housekeeping and maintenance were responsible for checking the cleanliness and temperatures of residents' refrigerators, but these tasks had not been performed. The facility's policy required maintenance staff to record refrigerator temperatures weekly and for nursing or housekeeping staff to clean the refrigerators weekly and discard any non-compliant foods. The lack of adherence to these procedures resulted in unsanitary conditions and the absence of temperature monitoring for the resident's refrigerator.
Failure to Maintain Required 1:1 Supervision for Aggressive Resident
Penalty
Summary
The facility failed to protect residents from physical abuse and neglect, specifically by not ensuring continuous one-to-one monitoring for a resident with a documented history of aggressive behavior towards another resident. The resident in question had multiple diagnoses, including frontotemporal neurocognitive disorder and vascular dementia with behavioral disturbances, and was known to display physical and verbal aggression towards others every 1–3 days. Despite repeated incidents—such as attempting to stab a roommate with a utensil, hitting another resident with a broom, and striking a resident in the face—interventions in the care plan were limited to documentation, physician notification, and psychiatric referral as needed. The care plan was updated to reflect the risk, but the resident was removed from 1:1 monitoring following an IDT meeting that did not include the psychiatric nurse practitioner (PNP), who had previously recommended continued 1:1 supervision due to ongoing aggression. The decision to discontinue 1:1 monitoring was made by the IDT, which included the Administrator, DON, and other staff, but excluded the PNP and did not document the information reviewed. Staff interviews revealed that the resident continued to display fixation and aggression towards the targeted resident, and that staff felt 1:1 monitoring was necessary to prevent further incidents. Multiple staff members, including nurses and CNAs, described ongoing altercations and the inability to keep the two residents separated within the secured unit. The psychiatric provider and several staff members expressed concern that removing 1:1 monitoring increased the risk of harm, but their input was not included in the decision-making process. Facility policy required monitoring, prompt reporting, and care plan updates for resident-to-resident altercations, as well as psychiatric consultation and possible transfer if care could not be provided safely. However, the facility did not follow these protocols consistently, as evidenced by the lack of continuous 1:1 monitoring and incomplete interdisciplinary involvement in care planning. The failure to maintain required supervision and to include all relevant providers in care decisions resulted in repeated aggressive incidents and placed residents at risk for harm.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Unsupervised Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with dementia and a high risk of elopement exited a secure unit unsupervised. The resident, who had a history of wandering and moderate cognitive impairment, was able to leave the secure unit after the assigned RN left the area to respond to a code elsewhere in the building. At the time, the only CNA assigned to the unit was on lunch break, leaving the secure unit without staff supervision. The secure unit door did not latch properly behind the RN, allowing the resident to follow and exit the unit. The resident proceeded through a side exit and entered the passenger seat of a parked fire truck in the facility's parking lot. Video footage confirmed that the resident left the secure unit, walked through the building, exited through a side door, and entered the fire truck without any staff or emergency personnel present in the area. The resident was later redirected back to the secure unit by another staff member after being observed near the facility's main entrance. Interviews with staff revealed a lack of clear protocols regarding code response and supervision coverage for the secure unit. The RN who left the unit stated he had not received training on code response teams and believed he was required to respond to all codes, despite no formal direction from the facility. The DON and other staff confirmed there was no policy specific to the secure unit, and staff had not received recent in-service training on elopement prevention or supervision. The facility's failure to ensure adequate supervision and secure door function resulted in the resident's unsupervised exit and placed residents at risk.
Failure to Provide Consistent Pressure Ulcer Prevention and Wound Care
Penalty
Summary
A deficiency occurred when a male resident with spastic quadriplegic cerebral palsy and other medical conditions developed a wound on his right calf due to friction from his wheelchair. Despite being identified as at risk for pressure ulcers, the resident did not have any wound care or therapy consult orders in place for nearly two months. Progress notes indicated that the wound was first documented as an abrasion with redness and was treated with normal saline, TAO, and a dry dressing, but there was no further documentation or follow-up on the wound for almost a month. Weekly skin assessments, as required by facility policy, were not completed for the resident. The last documented skin assessment before the deficiency was on 4/10, with the next not occurring until 5/29, despite the presence of a wound. During this period, there was no evidence of ongoing wound care, therapy consultation, or reassessment, and the wound deteriorated, developing granulation tissue and slough. The resident reported ongoing pain and that the wound had worsened due to continued friction from the wheelchair, with only a towel provided as a temporary measure. Interviews with staff revealed lapses in the facility's wound care processes, including a gap in wound care nurse coverage and issues with the electronic medical record system not generating skin assessment reminders. The charge nurses were responsible for weekly skin assessments during the interim, but these were not completed as required. The facility's own policy mandates weekly full-body skin assessments and thorough documentation, which was not followed in this case, resulting in inadequate care and monitoring of the resident's wound.
Failure to Administer Parkinson's Medication on Time
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for a resident diagnosed with multiple conditions, including Parkinson's Disease, Type 2 Diabetes, Asthma, Hypertension, major depressive disorder, and Epilepsy. The resident had a physician's order for Rytary (Carbidopa-Levodopa) to be administered three times daily for Parkinson's Disease, with the facility's policy requiring medications to be given within one hour before or after the scheduled time. Record review revealed multiple instances over a 14-day period where the resident's Parkinson's medication was administered late, ranging from over an hour to more than five hours past the scheduled time. The care plan specifically noted the need to administer medications as ordered to prevent complications related to Parkinson's Disease. Interviews with the resident, DON, and MD confirmed awareness of the late medication administration. The resident reported increased tremors, difficulty holding objects, and slurred speech when medications were late, particularly with the first and last doses of the day. The DON acknowledged ongoing issues with late medication administration, attributing delays to the use of agency nurses unfamiliar with residents and medication routines. The MD also confirmed knowledge of the problem and emphasized the importance of timely administration for Parkinson's medications. Facility policy review supported the expectation for timely medication administration, which was not met in this case.
Failure to Maintain Sanitary Kitchen Environment Due to Pest Infestation and Inadequate Cleaning
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary kitchen environment, as evidenced by multiple observations of dead cockroaches and food debris in various areas of the kitchen, including the entryway, underneath storage racks, inside a floor drain beneath a prep sink, and around the ice machine. The kitchen floors were found to be stained and dirty, with visible debris and dead insects present during multiple observations. Staff interviews revealed that the kitchen was short-staffed, and cleaning was not consistently performed as required. The dietary supervisor acknowledged the presence of dead bugs and stated that pest control was expected soon, but thorough cleaning was lacking due to staffing shortages. The maintenance supervisor confirmed the presence of American cockroaches and indicated that pest control visits occurred, but also noted that kitchen staff were responsible for daily cleaning, which was not being logged or consistently performed. Further interviews with the DON and ADM revealed a lack of awareness regarding the extent of the infestation and inconsistencies in cleaning practices. The DON was unaware of the cockroach problem in the kitchen and noted that trays were sometimes left unwashed late into the evening, while the ADM stated that kitchen staff should immediately remove bugs and maintain cleanliness, but admitted there was no log to track cleaning activities. The facility's sanitation policy required the food service area to be kept clean and free from pests, but these standards were not met, resulting in unsanitary conditions that could affect food safety.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
A certified nursing assistant (CNA) failed to perform proper hand hygiene while serving and assisting residents with their meals in the facility's only dining room. During observation, the CNA was seen carrying meal trays from the kitchen cart to residents and assisting them by setting up trays, unwrapping utensils, and opening drinks, without using hand hygiene between each tray passed. The CNA admitted during an interview that he had passed four trays without performing hand hygiene, despite having received training on the importance of hand hygiene between each tray. He acknowledged that this practice was not acceptable and could lead to cross contamination and illness among residents, particularly those who are older and more vulnerable. The Director of Nursing (DON) and the Administrator (ADM) both confirmed their expectations that staff should sanitize their hands before and in between passing trays, either by washing hands or using hand sanitizer. Both expressed concerns about the risk of cross contamination and infection, especially given the facility's population at risk for infection. Review of the facility's hand hygiene policy indicated that all personnel are to follow hand hygiene procedures, including before and after handling food or assisting residents with meals. The failure to adhere to these procedures was observed and acknowledged by staff, placing residents at risk for the development and transmission of communicable diseases and infections.
Failure to Ensure Call Light Accessibility for Resident with Severe Impairments
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. The resident, a male with severe cognitive impairment, legal blindness, muscle weakness, and dependence on staff for multiple activities of daily living, was observed twice in his wheelchair with his call light hanging over his nightstand approximately two feet away, making it inaccessible. The resident stated he was unaware of the call light's location due to his legal blindness and reported that staff never clipped the call light to him, leaving him unable to call for assistance unless he moved himself into the hallway or waited for staff to enter his room. Interviews with CNAs, the DON, and the administrator confirmed that it was the responsibility of all staff to ensure call lights were within reach of residents at all times. Both CNAs working the hall where the resident resided were unaware that the call light was not accessible to the resident. The facility's policy required staff to secure call lights within reach and to evaluate residents for special accommodations to use the call system, but these procedures were not followed for this resident.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and misappropriation of resident property were reported to the State Survey Agency within 24 hours as required. Specifically, an incident occurred in which one resident pushed or hit another resident in the chest area while passing in the hallway. The incident was reported to the charge nurse by the affected resident, and the Administrator (ADM) was informed on the same day. However, the ADM delayed reporting the alleged abuse to the Health and Human Services Commission (HHSC) until three days after the incident, despite being responsible for timely reporting. The delay occurred as the ADM was conducting an internal investigation and receiving conflicting accounts from the residents involved. Both residents involved had significant medical histories, including end stage renal disease, hypertension, osteoarthritis, cerebral infarction, type 2 diabetes, and vascular dementia. One resident was cognitively intact, while the other had moderate cognitive impairment. Interviews with both residents indicated that neither felt unsafe or injured after the incident, and both described the event as a push to get by in the hallway. The Director of Nursing (DON) confirmed that it was the ADM's responsibility to report such incidents promptly to prevent further abuse, and the ADM acknowledged the failure to report within the required timeframe.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in multiple deficiencies in food storage, preparation, and distribution. Observations revealed that food items in the pantry and walk-in refrigerator were not properly labeled or dated, with some items being out of date or moldy. Additionally, the kitchen environment was unsanitary, with dirty vents, utensils stored in a dirty drawer, and a dirty fryer with grease. The cereal containers were not properly labeled or sealed, and there was blood on the walk-in refrigerator floor. These conditions were observed during a survey, indicating a lack of compliance with infection prevention and control measures. Furthermore, the facility staff failed to take the temperatures of all food items being served to residents, which is a critical step in ensuring food safety. Specific food items such as hot dogs, beans, chili, meatloaf, mashed potatoes, tomato soup, gravy, and Salisbury steak were not temperature-checked before being served. This oversight in monitoring food temperatures could potentially lead to serving food at unsafe temperatures, increasing the risk of food-borne illnesses among residents. Additionally, staff members, including an LVN and a CNA, did not practice proper hand hygiene while distributing food and drinks in the secure unit dining room. Despite being aware of the facility's hand hygiene policy, both staff members admitted to neglecting to sanitize their hands before and after handling food trays. This lapse in hand hygiene practices poses a risk of cross-contamination and the spread of infections among residents. The facility's infection control policy emphasizes the importance of maintaining a safe and sanitary environment, yet these deficiencies highlight significant gaps in adherence to these standards.
Lack of Privacy and Grievance Resolution in Resident Meetings
Penalty
Summary
The facility failed to provide residents and family groups with a private space for meetings, as observed during a survey. The dining room was used as the designated meeting area, with only a temporary curtain providing minimal privacy. This setup did not adequately obstruct the view or sound, compromising the residents' ability to discuss their needs and preferences openly. Interviews with residents revealed that they were unaware of who the grievance official was and felt that their grievances were not being addressed or resolved. The facility also failed to follow up on concerns and requests expressed in resident council meetings over several months. Residents reported ongoing issues with food quality, such as cold meals and excessive pasta, as well as unresolved grievances about missing clothing items. Specific residents expressed dissatisfaction with the dietary options and the condition of drinks served. Additionally, there were complaints about infrequent changes of bed sheets and missing personal items from the laundry. Interviews with staff, including the DON and ADM, indicated that the facility did not have a social worker on staff to handle grievances, leading to a lack of follow-up and resolution. The DON and ADM claimed to be managing grievances in the interim, but residents reported not being informed of outcomes. The facility's grievance process was not effectively communicated or executed, leaving residents feeling that their concerns were not prioritized.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations of unclean and disrepaired conditions in residents' rooms and bathrooms. During the survey, it was noted that the facility did not repair cracks and holes in the walls, clean dust and dirt from ceilings and air vents, or maintain the cleanliness of toilets and bathroom floors. Additionally, trash was not regularly emptied, and bathroom vents were not properly repaired. These deficiencies were observed in the rooms and bathrooms of several residents, including Resident #59, Resident #74, and Resident #6. Resident #59's room and bathroom were found to be particularly neglected, with dust and dirt on the ceiling and air vents, mold around the air vent, and a leaking toilet with a stained towel at its base. The bathroom floor was dirty, and the toilet seat and rim were stained with feces. Resident #59 reported that his room had not been cleaned for several days and that housekeeping services were irregular and inadequate. Similar conditions were observed in Resident #74's and Resident #6's rooms, with dirty floors, stained walls, and unemptied trash cans. Resident #6, who is mostly non-verbal, indicated a desire for her room to be cleaned. Interviews with facility staff, including housekeeping and maintenance personnel, revealed that while there are cleaning schedules and maintenance protocols in place, they are not consistently followed. Housekeeping staff reported being familiar with their duties and schedules, but acknowledged that the size of the facility and its needs sometimes led to delays in completing tasks. Maintenance staff also noted that unresolved issues could pose safety hazards to residents. The facility's policies on cleaning and maintenance were reviewed, indicating that surfaces should be cleaned regularly and maintenance issues addressed promptly, but these standards were not met, leading to the observed deficiencies.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents received services with reasonable accommodations for their needs and preferences, specifically regarding the accessibility of call lights. Resident #68, a moderately cognitively impaired female with multiple health conditions including congestive heart failure and cerebral infarction, was observed on two occasions with her call light out of reach, lying on the floor at the end of her bed. Despite being dependent on staff for various activities, the resident was unable to demonstrate reaching the call light, which was confirmed by a CNA who acknowledged the resident's inability to reach it and the importance of call light accessibility. Similarly, Resident #55, a severely cognitively impaired male with diagnoses including mood disorder and schizophrenia, was observed sitting in the middle of the room without access to a call light. The resident was moaning and attempting to remove his sweater without success, remaining unattended for nearly 10 minutes before staff assistance arrived. Interviews with multiple CNAs and the DON confirmed that the resident's placement in the middle of the room without a call light was not typical or acceptable, and it was acknowledged that such a situation could lead to potential falls or unmet needs. The facility's policy on call light accessibility, revised in July 2023, emphasizes the importance of ensuring call lights are within reach to facilitate timely responses to residents' needs. Despite staff training on resident rights and call light placement, the observations and interviews revealed a failure to adhere to these guidelines, potentially compromising the safety and well-being of the residents involved.
Privacy Breach: Resident's Medical Information Exposed
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal medical records. During an observation, a registered nurse (RN) left a laptop open and unattended in the hallway, displaying a resident's information while performing wound care. This occurred after the RN had closed the resident's door, leaving the laptop visible to others in the hallway, including other residents and staff. The RN acknowledged that she usually closed her computer but had inadvertently left it open, despite being trained on resident privacy and HIPAA regulations. The resident involved was a male with multiple diagnoses, including sepsis, pleural effusion, dementia, and chronic kidney disease. He was severely cognitively impaired and required assistance with daily activities. The facility's administration and director of nursing confirmed that staff had been trained on maintaining resident privacy and confidentiality, and acknowledged that leaving a resident's information exposed violated HIPAA laws. The facility's policy on resident rights emphasized the importance of privacy and confidentiality, which was not upheld in this instance.
Failure to Obtain Hospice Documentation for Resident
Penalty
Summary
The facility failed to obtain necessary hospice documentation for Resident #246, who was admitted to hospice care. This included the hospice nursing documentation, the most recent hospice plan of care, the hospice election form, physician certification and recertification of the terminal illness, names and contact information for hospice personnel, hospice medications information, and physician orders. This deficiency was identified during a review of Resident #246's records and interviews with facility staff. Resident #246, a male with a history of sepsis, heart failure, hypertension, and chronic kidney disease, was admitted to hospice care with Hospice Medicaid Texas as the primary payor. Despite being on hospice care, there was no order specifying the hospice company providing care, and the necessary hospice documentation was not available in the resident's medical record. The lack of documentation could lead to confusion about the resident's care and the services being provided. Interviews with facility staff, including an LVN and the DON, revealed that the charge nurses were responsible for obtaining hospice orders and placing them into the electronic medical record. However, Resident #246 did not have a hospice folder with the required documentation, which could result in confusion about the hospice services being provided. The facility's policy requires coordination with hospice representatives and obtaining specific documentation to ensure quality care, but this was not adhered to in the case of Resident #246.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to protect its residents from abuse, specifically in two incidents involving resident-on-resident altercations. In the first incident, a resident with severe cognitive impairment due to dementia physically assaulted his roommate by punching him. This incident was not reported to the state office, as the facility's administration did not perceive the aggressor as a threat, and no injuries were documented. The resident's care plan was not updated following this incident, which may have contributed to a subsequent altercation. In the second incident, the same resident engaged in another altercation with a different roommate, where he used a wheelchair to physically abuse the roommate. This incident was reported to the state office, as it was discovered by staff and involved possible physical contact, although no injuries were reported. The facility's administration again did not view the resident as the aggressor, and the resident was subsequently moved to a private room in the Memory Care Unit. Interviews with staff revealed a lack of clarity and consistency in reporting procedures for resident-on-resident abuse. Some staff members believed the initial incident should have been reported within the required two-hour window, as per the facility's policy. The facility's policies on abuse, neglect, and resident rights emphasize the importance of immediate reporting and intervention to prevent further incidents, yet these protocols were not adequately followed in the first incident.
Failure to Implement Comprehensive Care Plan for Resident with Aggressive Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan (CCP) for a resident with severe cognitive impairment, who was involved in multiple resident-on-resident altercations. The resident, diagnosed with dementia, exhibited physical behaviors due to poor impulse control. Despite incidents of aggression towards roommates, the facility did not update the resident's CCP after an altercation on August 18, 2024, where the resident hit a roommate. This lack of action left other residents at risk of physical harm and mental anguish. The resident's CCP, initiated and revised on August 22, 2024, included interventions for nursing staff to analyze triggers, assess needs, and modify the environment to prevent agitation. However, these interventions were not implemented following the initial incident. The facility did not report the August 18 incident to the state office, as there were no injuries, and the administration did not perceive the resident as a threat. This decision was made despite staff opinions that the incident constituted abuse and should have been reported. Subsequently, on August 22, 2024, the resident was involved in another altercation with a different roommate, which was reported to the state office. The facility's failure to update the CCP after the first incident and the lack of timely reporting contributed to the recurrence of aggressive behavior. Interviews with staff revealed a consensus that addressing the initial incident in the CCP could have prevented the subsequent altercation. The facility's CCP policy required updates when desired outcomes were not met, but this was not adhered to in this case.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report an incident of physical abuse between two residents within the required two-hour timeframe. On 8/18/2024, Resident #1, who had severe cognitive impairment due to dementia, hit his roommate, Resident #2, after being disturbed while sleeping. Despite the incident being documented in the progress notes, it was not reported to the state office as required by the facility's policies. The facility's administrator decided not to report the incident, citing the absence of injuries and the belief that Resident #1 was not a threat to others. Resident #2, who also had severe cognitive impairment and was diagnosed with legal blindness and schizoaffective disorder, was found with a bruise on his left upper arm following the altercation. The bruise was noted during a skin assessment, and Resident #2's responsible party was informed of the incident. Despite this, the facility did not complete a 5-day provider investigation as required. Interviews with staff revealed a lack of clarity on why the incident was not reported, and the administrator confirmed the decision not to report was his own. The facility's policies on abuse reporting and resident-to-resident altercations were not followed, as the incident was not reported within the two-hour window, and no follow-up investigation was conducted. Staff interviews indicated that they were trained on abuse, neglect, and resident-on-resident altercations, yet the administrator's decision overrode these protocols. The failure to report and investigate the incident could have placed residents at risk of further harm and mental anguish.
Phone System Malfunction Affects Resident Communication
Penalty
Summary
The facility failed to ensure that residents received services with reasonable accommodation of their needs and preferences, specifically regarding the functionality of the phone system. Interviews and record reviews revealed that the facility's phone system was not consistently working, leading to issues with receiving incoming calls. Family members reported that calls to the facility would ring only a couple of times before disconnecting, and some calls went unanswered. This problem had been ongoing for a couple of months, and staff members, including the social worker and nurses, had to provide their personal cell phone numbers to family members to ensure communication. Staff interviews indicated that the phone issues were more prevalent on weekends, with ringers sometimes turned off or down, preventing calls from being noticed. The Director of Nursing (DON) and other staff members were aware of the problem and had reported it to the administration. The Maintenance Supervisor (MS) mentioned that the phones ran off the internet, making troubleshooting more challenging. Despite a technician reprogramming the phones three months prior, the issue persisted, and a technician was scheduled to address the problem. The facility's policy on resident rights emphasized the importance of communication access, which was compromised due to the phone system issues.
Failure to Provide Scheduled Showers and Document Refusals
Penalty
Summary
The facility failed to ensure that two residents, who were unable to perform activities of daily living independently, received necessary services to maintain good hygiene. Resident #1, a male with multiple diagnoses including hypertension, Crohn's disease, and schizoaffective disorder, required partial/moderate assistance with bathing. Despite being scheduled for showers on Mondays, Wednesdays, and Fridays, he only received five showers over a month-long period. There was no documentation of bathing being offered or refused, nor any negotiation of ADL times as per his care plan. Resident #1 expressed dissatisfaction, stating he felt neglected by the staff. Resident #2, also a male with diagnoses including type 2 diabetes and dementia, required supervision or touching assistance for bathing. He was scheduled for showers on alternate days but only received seven showers in the same period. The facility's records did not document any refusals of bathing, and Resident #2 could not recall how often he was offered showers. The facility's staff, including the ADON and CNAs, acknowledged the expectation to document refusals and educate residents on the importance of bathing, but there was a lack of consistent documentation. Interviews with facility staff, including the DON, ADON, and CNAs, revealed that there was an expectation for CNAs to notify nurses if a resident refused a shower, and for nurses to document the refusal and any education provided. However, there was no evidence of such documentation for the residents in question. The facility had conducted in-service training on shower schedules and refusals, but the deficiency in documentation and adherence to scheduled bathing persisted, potentially impacting residents' hygiene and dignity.
Inadequate Infection Control Practices with Blood Pressure Monitor
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of medical assistants (MAs) who did not sanitize a wrist blood pressure monitor between uses on multiple residents. Specifically, MA A used the monitor on two residents consecutively without cleaning it, and MA B, while supervising MA C, also failed to sanitize the monitor between residents. This oversight was observed during a survey, and the MAs involved did not adhere to the facility's infection control protocols. The residents involved in this deficiency had various medical conditions, including hypertension, diabetes, dementia, and cognitive impairments, which could make them more vulnerable to infections. The failure to sanitize the blood pressure monitor between uses on these residents could potentially increase the risk of disease transmission. Despite receiving training on infection control, MA A expressed a misunderstanding of the importance of sanitizing medical equipment between residents, believing that cleaning at the end of the shift was sufficient. The Director of Nursing (DON) acknowledged the deficiency and noted that the facility's policy clearly outlines the need for sanitizing medical equipment between residents. However, the in-service records revealed that there had been no specific training on the disinfection of medical equipment in recent months. The DON recognized the need for further education for staff, particularly for MA A, who demonstrated limited insight into proper infection control practices.
Failure to Implement Comprehensive Care Plan for Dialysis Compliance
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with end-stage renal disease, who was non-compliant with hemodialysis (HD) treatments. The care plan did not include the resident's behavior of refusing HD and lacked interventions to address this issue. Despite the resident's intact cognition and awareness of the importance of attending dialysis, he frequently refused treatment due to feeling unwell, leading to missed appointments. The facility also failed to notify the kidney center (KC) about the resident's refusal to attend HD sessions on specific dates, which was a requirement outlined in the care plan. The nursing staff documented the resident's refusal and notified the nurse practitioner (NP), but there was no record of communication with the KC. The KC attempted to contact the facility multiple times without success, resulting in the resident being sent to the emergency room after missing several HD sessions. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the care plans were not updated to reflect the resident's refusal of care. The DON acknowledged that the nursing staff was responsible for notifying the KC and that the care plan should have included interventions for the resident's non-compliance. The facility's policy emphasized the need for comprehensive, person-centered care plans with measurable objectives and timeframes, which were not adhered to in this case.
Failure to Address Resident's Nutritional and Hydration Needs
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there was a significant change in the resident's physical status. A resident was admitted to the hospital with severe dehydration and non-traumatic rhabdomyolysis, conditions that were not promptly identified or addressed by the facility. The resident's meal intake had decreased, but the facility did not notify the nutritionist, nurse practitioner (NP), or primary care physician (PCP) to address these nutritional or hydration concerns. The resident, who had a history of dementia, Parkinson's disease, anxiety, and depression, was admitted to the facility for respite care. The care plan did not include interventions for nutritional or fluid intake needs, and there were no physician's orders for the resident's diet or fluid intake. The resident's representative was not informed of the resident's declining condition, and the PCP was not contacted regarding any issues related to the resident. The facility's Director of Nursing (DON) stated that fluid intake was not tracked unless there was an order, and supplemental shakes were provided without documentation of consumption. Interviews revealed that the resident had not eaten or drunk anything for three days, leading to severe dehydration and rhabdomyolysis. The facility did not have a hydration policy, and the DON admitted that the facility did not address the eating or drinking issues with the NP or PCP, relying instead on the resident's representative's advice. The hospital treating physician confirmed that the resident's condition was consistent with lying in bed without nutrition or hydration for an extended period.
Failure to Monitor Nutritional and Hydration Needs Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, leading to severe dehydration and non-traumatic rhabdomyolysis. The resident, who had a history of dementia, Parkinson's disease, anxiety, and depression, was admitted to the hospital after showing signs of lethargy, inability to stand, pale skin, and purple fingertips. The facility did not identify the resident's decreased meal intake or notify the nutritionist, nurse practitioner, or primary care physician to address these concerns. The resident's care plan did not include interventions for nutritional or fluid intake needs, and there was no physician's order for the resident's diet or fluid intake. Meal intake records showed that the resident consumed less than 25% of his dinner on several occasions, and there was no record of dinner eaten on one day. Despite being informed of the resident's swallowing problems, the facility did not adequately monitor or document the resident's fluid intake or provide necessary interventions. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's nutritional and hydration needs. The Director of Nursing admitted that the facility did not have a hydration policy and relied on standard protocol without documenting interventions. The resident's condition deteriorated, resulting in hospitalization and a subsequent decision to place the resident on hospice care. The facility's failure to monitor and address the resident's nutritional and hydration needs contributed to the resident's decline in health.
Failure to Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report an incident involving Resident #1's fall in a timely manner. Resident #1, who had multiple diagnoses including COPD, dementia, and congestive heart failure, fell on 4/15/2024, resulting in a facial injury. Despite the fall being witnessed by staff and EMTs, the incident was not reported to the state agency immediately. Interviews with staff revealed confusion and a lack of communication regarding the incident, with the DON only informing the AD on or about 4/22/2024, after Resident #1 had passed away in the hospital. The facility's policy on abuse and neglect reporting was not followed, as the incident was not reported within the required timeframe. The facility also failed to report an incident of resident-on-resident abuse involving Resident #2 and Resident #3. On 4/03/2024, Resident #3 attempted to grab Resident #2's pants. The incident was documented by the DON, who assessed both residents and found no signs of trauma. However, the incident was not reported to the state agency as required. The DON and the administrator concluded that the incident was not reportable, despite the facility's policy stating that all allegations of abuse must be reported immediately. Interviews with the DON and the administrator revealed a lack of understanding and adherence to the facility's abuse reporting policy. The DON stated that she followed the administration's advice not to report the incident, while the administrator acknowledged that the incident should have been reported. The facility's failure to report these incidents in a timely manner could place residents at risk for abuse, neglect, and a decreased quality of life.
Failure to Investigate and Report Allegation of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report the results of an allegation of abuse and neglect involving a resident who fell. The resident, a [AGE] year-old female with multiple diagnoses including COPD, dementia, hypertension, congestive heart failure, mood disorder, acute respiratory distress, and chronic pain, was found on the floor by EMTs. Despite the incident, the facility did not complete an investigation or report the findings within the required five working days. The Director of Nursing (DON) and the Assistant Director (AD) both acknowledged gaps in communication and understanding of the incident, which led to the failure to investigate and report appropriately. The DON stated that she was informed by RN A about the resident being sent to the ER and later about the resident being found on the floor. The Therapy Director provided conflicting accounts about the incident, which added to the confusion. The AD admitted to not being aware of the unwitnessed fall and did not ensure an investigation was conducted. The facility's policy on abuse, neglect, exploitation, or misappropriation requires all allegations to be thoroughly investigated and reported, but this protocol was not followed in this case.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage, labeling, and sanitation practices in the kitchen. Observations revealed that food products were not sealed in airtight containers, lacked labels indicating the product name, open date, or discard date, and were not disposed of after their expiration dates. Specific instances included a box of pineapple tidbits stored directly on the floor and various food items in the walk-in cooler and freezer that were not properly sealed or labeled. Additionally, the facility's kitchen equipment and food preparation areas were not adequately cleaned and sanitized. The industrial can opener and its mounting bracket were found to be coated with a dark brown substance and food particles, while the dishwasher and its surrounding area had accumulations of white grit, food particles, and grime. These unsanitary conditions posed a risk of cross-contamination and the spread of food-borne pathogens, potentially endangering the health of residents. Interviews with staff, including the Dietary Aide (DA), Kitchen Manager (KM), Director of Nursing (DON), and Administrator (ADM), highlighted a lack of adherence to established food safety protocols. The KM admitted that the failure to properly label and date food products and sanitize preparation areas was due to staff not following instructions and inadequate training. The DON and ADM acknowledged the existence of facility policies on food safety and sanitation but noted that the kitchen's non-compliance was not reported or addressed by the Interdisciplinary Team (IDT).
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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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