Harmony Care At Beaumont
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaumont, Texas.
- Location
- 2660 Brickyard Rd, Beaumont, Texas 77703
- CMS Provider Number
- 675595
- Inspections on file
- 55
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 44 (5 serious)
Citation history
Health deficiencies cited at Harmony Care At Beaumont during CMS and state inspections, most recent first.
A facility failed to supervise residents while smoking and failed to keep smoking areas safe and an unoccupied room free of unsecured chemicals. A resident with aphasia and contractures, a resident with ESRD and heart disease, and a resident with stroke-related deficits were observed smoking without staff present or in an undesignated area near a water heater door, while a resident with bipolar disorder and seizures smoked on a secure-unit patio that lacked ash trays, fire safety equipment, and designated signage. An unlocked repair room also contained unsecured spray bottles, including bleach and diluted oven cleaner.
The facility failed to ensure RN coverage for 8 consecutive hours every day. Record review showed no RN coverage on multiple weekend days, and interviews with the HR, DON, and Administrator confirmed the facility had only 2 RNs during that period and they were not covering weekends.
Unsanitary kitchen conditions were observed when an uncovered piece of ham was left out and touching a dirty prep surface, the deep fryer contained brownish-black oil with thick grease and burnt food buildup, and a hallway trash can was overflowing with garbage and boxes piled about 3 feet above it and scattered on the floor. The DM acknowledged the ham should have remained refrigerated and covered, the fryer had persistent buildup, and the trash should have been removed before it overflowed.
Smoking Area Fire Cans Contained Trash: The facility failed to enforce its smoking policy in the main designated smoking area under the car port. An observation found two red fire cans containing cigarette butts, empty cigarette paper boxes, soda cans, chip bags, and other paper and plastic trash. The Maintenance Director said he was responsible for maintaining the smoking areas and emptying the fire cans, and the DON stated staff assisting residents with smoking should ensure there was no trash in the red fire can. The facility policy stated that ashtrays were to be emptied only into designated receptacles.
Call Light Not Left Within Reach After Care: A resident with metabolic encephalopathy, DM2, HTN, and immunodeficiency, and who was dependent for mobility and self-care with moderate cognitive impairment, had her call light left behind a roommate's dresser after brief care was completed. The CNA and LVN both stated they forgot to place the call light within reach, and the resident said she wanted it in her hand so she could call for help. The DON stated staff were expected to ensure residents had their call lights within reach.
MDS Assessment Incorrectly Coded Tobacco Use: A resident with ESRD, heart disease, depression, and anxiety was documented as a tobacco user on his smoking assessment and care plan, and he was observed smoking under supervision in the smoking area. However, his annual MDS was coded as not using tobacco. The MDS nurse said the assessment was miscoded, and the DON stated the MDS was expected to be accurate.
A resident with metabolic encephalopathy, dysphagia, immunodeficiency, and moderate cognitive impairment had a feeding tube noted on the MDS, but the baseline care plan did not include the g-tube. The MDS Nurse said she overlooked adding it, and the DON stated the baseline care plan should contain the information nurses need, including diet, treatments, goals, and interventions.
Failure to Provide Scheduled Shower and Bed Bath Care: A resident with moderate cognitive impairment, diabetes, HTN, and immunodeficiency did not receive scheduled shower/bed bath care and had no documented shower for several days. During observation, staff noted a foul odor, dry skin flakes, and greasy, uncombed hair; the resident said she was not offered an alternative bath day, while the CNA said it was her responsibility to ensure hygiene care was completed and reported if it could not be done.
Pest Control Program Not Effective: Surveyors observed live gnats, flies, and roaches in residents’ rooms. Two residents shared a room with gnats and flies, including a swarm coming from a garbage can, and two other residents shared a room where a large live cockroach and several additional roaches were seen near the beds, wall, dresser, and bathroom. Staff acknowledged the pest issues, noted the rooms needed to be logged or sprayed, and said pest control had been contacted, but live pests were still present during observation.
A cognitively impaired male resident with dementia and Alzheimer’s disease, assessed as severely impaired and rarely understood, was allegedly physically abused by a CNA during incontinence care after refusing care. Another CNA reported that the CNA forcibly pushed the resident onto the bed, manhandled him, hit his arms multiple times with a closed fist, pinned his hands, forcibly removed his shorts and brief, and then allowed him to walk out of the room with his lower body uncovered despite objections. The resident later showed no skin injury and could not recall the incident, while the alleged perpetrator denied the abuse and the reporting CNA and a family member confirmed and acted on the allegations.
Nursing and medication staff failed to consistently sign controlled drug count sheets at the start and end of their shifts, despite facility policy requiring shift-to-shift counting and documentation of controlled substances. Review of controlled drug records over several months showed multiple missing signatures by several LVNs and a medication aide on various halls and shifts, even though some staff reported they had performed the counts but forgot to sign. Leadership acknowledged that all nurses and MAs were responsible for signing the controlled drug sheets and that oversight of these records had been missed, and the report states this failure could place the facility at risk for drug diversion.
Multiple residents experienced abuse and neglect, including unwanted sexual contact, physical and verbal abuse by staff, and repeated resident-to-resident altercations. Incidents involved individuals with significant cognitive and behavioral impairments, and staff failed to intervene effectively to prevent or stop the abuse, despite known risks and documented behavioral histories.
The facility did not update or implement comprehensive care plans for several residents following incidents of aggression and inappropriate sexual behavior. After a male resident inappropriately touched a female resident, his care plan lacked new interventions to prevent further episodes. Similarly, care plans for residents involved in multiple altercations were not revised to address their evolving needs, and there was no effective system to ensure care plan updates were completed after such incidents.
Staff failed to immediately report multiple incidents of alleged abuse and resident-to-resident altercations to the abuse coordinator and state authorities as required. In one case, a staff member witnessed a CNA verbally and physically abuse a resident with cognitive impairments but delayed reporting the incident. In other cases, a nurse did not promptly report a physical altercation between two residents, and another incident involving a resident being scratched and injured was not reported to the administrator until the following day. These lapses resulted in delayed investigations and placed residents at risk.
Multiple rooms were found with dead cockroaches, missing baseboards, stained flooring, cracked and missing tiles, and a bathroom vanity with missing doors. Several residents reported that while their rooms were cleaned, bathrooms were not properly maintained and pest issues persisted. Facility staff, including the Administrator and Maintenance Director, were unaware of these issues, and no maintenance requests had been logged for the observed deficiencies. The Housekeeping Supervisor acknowledged inadequate cleaning practices and the absence of a cleaning checklist.
Two CNAs failed to follow hand hygiene protocols while providing incontinent care to a resident with diabetes, severe obesity, and moderate cognitive impairment. After cleaning the resident, the CNAs did not perform hand hygiene when changing gloves or moving from dirty to clean tasks, only sanitizing their hands after care was completed. Interviews indicated inconsistent understanding and training regarding hand hygiene requirements, despite facility policies and in-services outlining these procedures.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident with multiple complex diagnoses, including quadriplegia, diabetes, and depression, did not have several active conditions accurately documented in the MDS assessment. Staff interviews revealed confusion over responsibility for MDS accuracy, absence of a current MDS Coordinator, and lack of a specific MDS policy, resulting in incomplete assessment of the resident's health status.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Persistent foul odors were present in a hallway and several rooms due to some residents refusing hygiene care, despite repeated cleaning by housekeeping staff. Additionally, a resident's dresser remained in disrepair for months, with broken and missing handles and drawers that would not close, causing frustration for the resident. These issues resulted in an environment that was not consistently clean, comfortable, or homelike.
Surveyors observed live and dead cockroaches and spiders in multiple resident rooms, including pests on furniture and food trays. Several residents reported feeling distressed by the presence of pests. Staff and maintenance confirmed periodic pest sightings and documented ongoing issues in facility logs, despite regular pest control treatments and reporting procedures.
A resident with a history of mental health conditions expressed grievances about specific CNAs providing her care, citing improper care and feeling unsafe. Despite being cognitively intact and able to communicate her needs, the facility failed to adequately address her concerns, as the CNAs continued to be assigned to her. The facility's grievance policy was not followed, leading to unresolved issues and potential decreased quality of life for the resident.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, for 24 out of 45 days reviewed. Interviews and record reviews revealed staffing challenges, including difficulties in hiring RNs and ensuring consistent coverage. The facility's policy requires an RN to be onsite for 8 consecutive hours daily, which was not consistently met.
The facility failed to submit complete and accurate direct care staffing information to CMS for two quarters in 2024. This was due to oversight and confusion about responsibilities among staff, with the Regional Director of Clinical Operations and Corporate HR unaware of the need to ensure timely submission. The facility's policy on reporting staffing information was not followed, leading to the deficiency.
The facility failed to maintain essential equipment safely, including a gas stove with non-igniting burners, a walk-in freezer with a loose gasket, and a milk box with mildew. Additionally, an electric bed in a resident's room had a spliced electrical cord with exposed live wires. The issues were not reported by staff, and the facility's Maintenance Service policy was not followed.
The facility's kitchen had unsanitary conditions, with baking sheets and pans showing buildup, improperly labeled and expired food items, and inadequate sanitizing solution. These issues could risk foodborne illness among residents.
The facility failed to maintain a safe and sanitary environment, with issues in Hall 200, the dining room, and specific resident rooms. Observations showed discolored tiles, missing paint on door frames, and a buildup of debris. An unlocked closet labeled for oxygen storage was found with black fuzzy substance and spider webs. Interviews with staff confirmed awareness of these issues, but no documented plans for repairs were in place.
A facility failed to properly store medications, leaving a resident's nystatin powder unsecured on a bedside table. The resident, who was cognitively intact and had diabetes, was unaware of the powder's presence. Interviews with the ADON and Administrator confirmed that medications should not be left in resident rooms and should be stored in the medication cart when not in use.
Two residents with cognitive impairments were involved in a sexual abuse incident in the dining room, highlighting a failure in the facility's protective measures. Despite having care plans addressing inappropriate sexual behaviors, the incident occurred, indicating a lapse in intervention implementation.
The facility failed to report abuse allegations involving four residents to the State Agency within the required 2-hour timeframe. In one case, a resident with cognitive impairment assaulted another resident, and in another, a resident with mental health issues attacked a fellow resident. Both incidents were documented, but the reports were delayed, violating the facility's policy for immediate notification.
A facility failed to implement the PASRR comprehensive service plan for a resident with schizoaffective disorder, cerebral palsy, dysphagia, and aphasia. The resident was identified as PASRR positive for intellectual disability, and the plan recommended specialized therapies. However, these services were not provided within the required timeframe due to authorization issues, delaying the initiation of therapy services. The facility did not meet PASRR requirements for timely service initiation, as confirmed by the Regional Director of Reimbursement.
A resident with dementia and a history of inappropriate sexual behavior was involved in two incidents of touching female residents' breasts. Despite interventions, the facility failed to ensure adequate monitoring and documentation, leading to an Immediate Jeopardy situation. Staff interviews revealed inconsistencies in awareness and reporting, highlighting deficiencies in the facility's abuse prevention policy.
A resident with a history of inappropriate sexual behavior was not adequately monitored, leading to incidents of inappropriate touching of two other residents. The facility failed to implement its policies for preventing abuse, neglect, and exploitation, resulting in a deficiency. Staff did not maintain one-on-one monitoring or update care plans, despite the resident's known behaviors.
The facility failed to maintain a full-time DON and consistent RN coverage, lacking a DON from mid-August to late September and missing RN coverage on several days in September. The Administrator was unaware of the option to use agency nurses for RN coverage, and the facility lacked a policy for ensuring proper staffing.
A facility failed to limit PRN orders for psychotropic drugs to 14 days without proper documentation, affecting three residents. One resident with dementia and delusional disorder received Ativan without a stop date or behavior monitoring. Another resident with schizoaffective disorder received PRN Ativan injections without a pharmacy review. A third resident with dementia and anxiety received Lorazepam without a stop date. Staff interviews revealed a lack of awareness of the 14-day requirement and inadequate monitoring of behaviors and side effects.
A facility failed to report allegations of sexual abuse involving a resident with dementia who inappropriately touched two female residents on separate occasions. Despite the facility's policy requiring immediate reporting, the incidents were not reported to the state agency, potentially placing residents at risk. Staff interviews revealed a lack of clarity and communication regarding the reporting process.
The facility failed to address significant weight loss and nutritional needs for five residents, leading to severe weight loss without appropriate dietary interventions. Despite care plans and dietician recommendations, there was a lack of communication and implementation of necessary dietary changes, resulting in unaddressed weight loss and potential health decline.
A resident with a PICC line did not have their dressing changed as ordered, and a treatment nurse failed to follow proper hand hygiene protocols during wound care. The facility's infection control policies were not adhered to, leading to potential infection risks.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with multiple health conditions, including cellulitis and diabetes. The absence of this care plan was confirmed through record reviews and staff interviews, highlighting a lapse in following the facility's policy, which mandates such plans to ensure immediate care needs are met.
A facility failed to maintain and revise a resident's care plan after it was mistakenly closed, despite the resident not being discharged. The resident, with multiple health conditions and severe cognitive impairment, did not have their care plan updated quarterly as required. Interviews revealed that the MDS Coordinator and DON were responsible for ensuring care plans were active and revised, but this was not done due to the error.
A resident with multiple diagnoses, including functional quadriplegia, did not receive appropriate contracture management at the facility. Despite severe flexed contractures and decreased ROM noted in an OT assessment, the resident was discharged from OT services without recommendations for a hand roll or positioning device due to lack of a payer source. Facility staff were unaware of the need for contracture management, and there was no documentation or care plan addressing the resident's condition, contrary to the facility's policies on joint mobility and rehabilitative nursing care.
A resident with schizophrenia was improperly discharged from an LTC facility before the end of a 30-day notice period. After being treated at a behavioral hospital, the facility refused to readmit her, citing safety concerns and lack of space. The resident was left at a local hospital, displaying no aggressive behaviors, while the facility had already given her bed to another resident.
A facility failed to follow its policy on readmitting a resident after hospitalization, leading to a deficiency. The resident, with a history of schizophrenia and mood disorder, was not allowed to return before the 30-day discharge notice period ended. The facility cited safety concerns and lack of space, despite the resident being discharged from a behavioral hospital. Staff were instructed not to readmit the resident, who was eventually taken to another hospital.
A resident in a long-term care facility expressed a grievance about a CNA, feeling unsafe and afraid, but the grievance was not documented or reported as required. Despite the resident's cognitive intactness, the grievance was not addressed by the staff, including a CMA and the CNA involved. The facility's policy mandates that grievances be documented and forwarded to the Grievance Official, but this was not done, resulting in a deficiency.
A resident with severe cognitive impairment and aggressive behaviors did not have a comprehensive care plan addressing these issues. Despite documented aggression, the facility failed to implement a care plan, leading to incidents where staff were physically attacked. Interviews revealed the omission was a mistake, highlighting the need for adherence to care planning policies.
The facility failed to conduct weekly skin assessments for three residents, as required by their care plans, due to a lack of scheduling and notification in the electronic record system. This oversight, involving residents with conditions like dementia, cellulitis, and hemiplegia, was identified through interviews and record reviews, revealing a risk of inadequate care and medical interventions.
A resident with severe cognitive impairment and a care plan requiring nail trimming was found with long, jagged fingernails, indicating a failure in maintaining personal hygiene. Staff interviews revealed a lack of awareness and documentation regarding the resident's nail care, with the DON unable to locate care sheets and the Administrator expecting staff to keep nails trimmed to prevent skin issues.
The facility failed to immediately notify the physician and responsible party after a resident placed a pillow over another resident's face, leading to a delay in medical intervention and potential harm.
The facility failed to protect two residents from abuse, including one incident where a resident was pulled out of her wheelchair and another where a resident placed a pillow over her roommate's face with intent to harm. There were delays in reporting, inadequate documentation, and insufficient immediate corrective actions.
A resident with schizophrenia and moderate cognitive impairment was involved in two aggressive incidents, including attempting to suffocate her roommate. The facility failed to implement immediate one-on-one supervision or other safety measures, and staff did not document the incidents properly or notify the necessary parties in a timely manner.
Unsafe Smoking Supervision and Unsecured Chemicals
Penalty
Summary
The facility failed to ensure adequate supervision for residents who smoked and failed to keep smoking areas and an unoccupied room free of hazards. Resident #14, a cognitively intact female with aphasia, dysarthria, dysphagia, muscle wasting and atrophy, and right shoulder and hand contracture, was observed smoking in a motorized wheelchair in an undesignated area outside, within about 10 feet of the door enclosing the water heater. She was unsupervised, had her cigarette close to her pants, and flicked the unextinguished cigarette onto the grass. She stated she knew the area was not a designated smoking spot and said she sometimes smoked there when staff was not outside with her. Her cigarettes were not in the box maintained by staff, and CNA A stated staff was responsible for supervising residents during smoke breaks until the last person was done. Resident #6, who had ESRD, heart disease, depression, and anxiety, was also observed smoking unsupervised in the same undesignated area near the water heater door. He was in a wheelchair, kept his cigarettes with him, and said he did not know who lit his cigarette. He stated he knew the area was not a designated smoking spot and said he had smoked there more than once without staff moving him. Resident #9, who had cerebral infarction, hemiplegia, and hemiparesis and a BIMS of 13, was observed smoking in the designated smoking area under the carport with no staff present. He said it was his choice to keep his cigarettes in his own possession and declined to say who lit his cigarette. Resident #33, who had bipolar disorder and seizures and a BIMS of 00, was observed smoking on the secure unit patio. The patio had cigarette butts on the ground near dry leaves, and there were no ash trays, fire cans, designated smoking signs, fire extinguisher, or fire blanket at the time of the observation. Staff interviews indicated residents on the secure unit smoked there, but the area was not designated for smoking. In addition, an unoccupied room with a closed-for-repairs sign but an unlocked door contained a maintenance cart with two spray bottles hanging on it, including one marked 10% bleach and one unmarked bottle later identified as diluted oven cleaner. Staff stated the chemicals should be secured, and the Maintenance Director immediately marked the bottle and locked the chemicals in the cart.
RN Coverage Not Maintained Every Day
Penalty
Summary
The facility failed to ensure an RN was on duty for 8 consecutive hours 7 days a week for 1 of 3 months reviewed for RN coverage. Record review of the RN time sheets for December 2025 showed no RN coverage on 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, 12/27/2025, and 12/28/2025. During interviews, the HR said corporate submitted information to PBJ and that she would review sign-in sheets and time sheets for those weekend dates, then later stated there were only 2 RNs during that period and they were not covering weekends. The DON said she started in January 2026 and was unaware whether the facility had RN coverage 7 days a week in December 2025, and the Administrator said his expectation was for an RN on duty 8 hours a day every day.
Unsanitary food storage, fryer buildup, and overflowing trash in kitchen
Penalty
Summary
Food was not stored, prepared, and served under sanitary conditions in the kitchen. During observation, an uncovered piece of ham approximately 10 inches by 4 inches was found in the refrigerator area, with half of it touching a prep table that had food particles and pieces of paper that had covered the ham. The DM stated the ham should not have been left out of the refrigerator and uncovered to prevent food borne illness. The deep fryer contained cooking oil that was brownish black and had thick black buildup of burnt grease and food particles around the top of the fryer. The DM stated the oil was changed weekly and as needed, and that sometimes thick burnt-on food particles did not always come off. In the kitchen hallway by the dry storage room, a 64-gallon rolling trash can had bags of garbage and empty boxes piled approximately 3 feet above the can, with garbage and empty boxes also on the floor around it. The DM stated the garbage should have been taken out before running over in the hallway and that the kitchen should be kept clean and free of garbage to prevent food borne illnesses and pest issues.
Smoking Area Fire Cans Contained Trash
Penalty
Summary
The facility failed to ensure that its smoking policies were formulated, adopted, and enforced for the main designated smoking area under the car port. During an observation on 04/13/26 at 12:20 p.m., the two red fire cans in that smoking area were found to contain cigarette butts, empty cigarette paper boxes, empty soda cans, chip bags, and other plastic and paper trash. The Maintenance Director emptied the trash from both fire cans and stated that he was responsible for maintaining the smoking areas, including emptying the red fire cans, and that he had done so that morning. He said he would schedule rounding more frequently and stated that the red fire cans should only contain cigarette butts because other trash could be a fire hazard. During an interview on 04/13/2025 at 4:00 p.m., the DON stated that the designated smoking areas were to be maintained by the Maintenance Director, but all staff who assisted residents to smoke should be mindful of the ashtrays and fire cans and ensure there was no trash in the red fire can. She said she would see to it that staff were re-trained on the smoking policy and maintenance of the smoking areas. Record review of the facility's Smoking Policy-Resident dated 2001 stated that the facility had established and maintained safe resident smoking practices, that metal containers with self-closing cover devices were available in smoking areas, and that ashtrays were emptied only into designated receptacles.
Call Light Not Left Within Reach After Incontinent Care
Penalty
Summary
The facility failed to ensure the nurse call system was accessible for one resident who was reviewed for resident call system use. Resident #30 was a [AGE]-year-old female admitted on 03/20/2026 with diagnoses including metabolic encephalopathy, type 2 diabetes, essential primary hypertension, and immunodeficiency. Her admission MDS indicated a BIMS score of 10, showing moderate cognitive impairment, and Section GG showed she was dependent and required 2 or more staff members for mobility and self-care needs. Her baseline care plan stated she was dependent on staff members for mobility and self-care needs. During an observation and interview on 04/13/2026 at 9:45 a.m., CNA Z was changing Resident #30's brief with assistance from LVN C. After the care was completed, neither staff member placed the resident's call light within reach. The call light was observed behind her roommate's dresser, approximately 10 feet from the resident. During interviews, the resident stated she knew the purpose of the call light, had used it before, and wanted it in her hand so she could call for help. CNA Z and LVN C each stated they forgot to place the call light within reach before leaving the room, and the DON stated she expected all staff entering the room to ensure residents had their call lights within reach. The facility policy stated residents are to be provided with a means to call staff for assistance and that the call system will be in reach of each resident at the resident's preference.
MDS Assessment Incorrectly Coded Tobacco Use
Penalty
Summary
The facility failed to ensure that Resident #6’s annual MDS assessment accurately reflected his tobacco use status. Resident #6 was admitted with diagnoses including end stage renal disease, heart disease, depression, and anxiety. His smoking assessment indicated that he used tobacco and required supervision, and his care plan identified him as a tobacco smoker at risk for injury with interventions related to designated smoking areas, smoking times, and smoking material control. The annual MDS assessment dated [DATE] was coded as indicating that Resident #6 did not use tobacco, even though the resident was observed in the smoking area being supervised while smoking on 04/14/2026 at 1:30 p.m. During interview, the MDS Nurse stated she must have miscoded the annual MDS assessment, and the DON stated the expectation was for the MDS assessment to be accurate. The CMS RAI Manual excerpt included in the record stated that if a resident used tobacco during the 7-day look-back period, the item should be coded yes.
Baseline Care Plan Missing G-Tube Information
Penalty
Summary
The facility failed to develop and implement a baseline care plan for one resident that included the instructions needed to provide effective and person-centered care. Resident #30 was admitted with diagnoses including metabolic encephalopathy, dysphagia, and immunodeficiency, and her admission MDS indicated a BIMS score of 10, showing moderate cognitive impairment. Section K of the MDS also indicated that she had a feeding tube. However, the baseline care plan dated 03/20/2026 did not include the resident's g-tube. Record review of the care plan history showed the next review date for the care plan was 03/27/2026, and it was 18 days overdue on 03/31/2026. During interview, the MDS Nurse stated she overlooked adding the g-tube to the care plan and that it should have been listed, and she acknowledged that the interdisciplinary team provided input but she was responsible for completing the baseline care plan after the assessment was completed. The DON stated the baseline care plan should contain the information a nurse needs to care for a resident, including ADLs, medications, diet, treatments, goals, and interventions, and agreed the care plan was insufficient because the g-tube was not included.
Failure to Provide Scheduled Shower and Bed Bath Care
Penalty
Summary
The facility failed to ensure Resident #30 received appropriate ADL care to maintain good personal hygiene when she did not receive a shower on 04/08/2026, 04/10/2026, and 04/13/2026. Resident #30 was a [AGE]-year-old female admitted on 03/20/2026 with diagnoses including metabolic encephalopathy, type 2 diabetes, essential primary hypertension, and immunodeficiency. Her admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and she was dependent on 2 or more staff members for showering/bathing. The shower/ADL log showed her last bed bath was on 04/06/2026, and there was no documentation of a shower between 04/08/2026 and 04/13/2026. During observation on 04/13/2026, CNA Z and LVN C were changing Resident #30’s brief, and a foul odor was noted in the room after the brief was removed. Resident #30 had white skin flakes around her mouth, cheeks, and forehead, and her hair appeared greasy and uncombed. Resident #30 stated staff did not take her to the shower room and that she had received bed baths by choice, but she also said she went without a bed bath for multiple days and was not offered an alternative day. CNA Z stated she smelled odor from the resident’s body, that hygiene wipes did not remove it, and that soap and water were needed; she also said she was not aware when the resident last had a bed bath and that it was her responsibility to ensure the resident received a shower or bed bath and report if it was not possible. The DON stated it was her expectation that the resident be offered and given a shower or bed bath on assigned days and as needed, and the Administrator stated CNAs were expected to provide showers/bed baths and ADL care on assigned days.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program for residents’ rooms that were observed to have live pests. Resident #6, who had end stage renal disease, heart disease, depression, and anxiety and had an intact BIMS score, and Resident #34, who had epilepsy and bipolar disorder and had moderate cognitive impairment, were observed in a room with gnats and flies. During the observation, there were flies landing on Resident #34’s bed and a swarm of approximately 40 to 50 gnats coming out of the garbage can. Both residents stated they wanted the bugs gone. Staff acknowledged the pest problem in the room. An LVN stated the room had gnats and flies and said it needed to be sprayed, and she would place the room on the pest control list. The maintenance director stated staff should have placed the room number on the pest control log, but they did not. The administrator stated the facility had found the source was a refrigerator and had started a cleaning process. The pest log reviewed for the prior months showed only two reports of flies and gnats in other rooms. The facility also failed to keep another room free of roaches for Resident #23 and Resident #45, both cognitively intact and diagnosed with essential hypertension and hyperlipidemia. During observation, a large live cockroach was seen moving across the room, along with three other live roaches on the floor and wall between the beds and near the dresser and bathroom. Both residents said the roaches kept coming back, and one resident said maintenance was aware of the problem. Staff stated the room had been sprayed about 2 to 3 weeks earlier, that the room was logged for pest control, and that the maintenance director had spot sprayed the room and called pest control back out for service. The maintenance book showed the previous roach log entry was dated 03/08/26.
Failure to Protect Cognitively Impaired Resident From Physical Abuse During Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA. The resident was an elderly male with dementia, anxiety disorder, and Alzheimer’s disease, admitted in February and assessed as severely cognitively impaired with a BIMS score of 3.0 and rarely/never understood. His care plan identified impaired cognition and risk for further decline and injury. Despite these vulnerabilities, the resident was subjected to alleged physical abuse during care provision by a CNA. According to a written statement from another CNA who was present, the incident occurred when the two CNAs attempted to provide incontinence care and the resident refused. After the resident refused care multiple times, the reporting CNA began to leave the room, at which point the other CNA allegedly tried to force the resident onto the bed. The resident became somewhat aggressive, and the CNA allegedly responded by manhandling him, forcing him into the bed, and, when the resident tried to push him away, hitting the resident on the arms approximately three to four times with a closed fist. The CNA then allegedly pinned both of the resident’s hands down, forcibly pulled down his shorts, and ripped off his brief, leaving him lying on the bed with his bottom uncovered. The reporting CNA stated she repeatedly told the other CNA to leave the resident alone and to report the situation, but he refused. When the CNA realized the resident would not allow him to complete the change, he allowed the resident to get up and walk out of the room with no clothing on his lower body. The reporting CNA attempted to stop the resident from leaving the room without pants, but the resident did not allow her to do so. The resident was later assessed multiple times with no skin injuries noted, and he was unable to recall any issues with staff during interview attempts. The alleged perpetrating CNA denied being rough or abusive, while the reporting CNA confirmed her written account during a subsequent phone interview. The resident’s family member later stated she filed charges against the CNA and described being extremely upset and traumatized by the incident.
Incomplete Controlled Drug Count Documentation by Nursing and Medication Staff
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate controlled drug count records and to ensure that all staff responsible for controlled medications signed the controlled drug count sheets as required. Review of controlled drug count sheets for multiple halls and shifts in January and February showed missing signatures from several LVNs and a medication aide on dates and shifts when they had responsibility for the medication carts. The controlled drug count forms stated that signing acknowledges the staff member has counted the controlled drugs on hand and verified that the quantity matches the Controlled Drug Administration Record, but these signatures were absent on numerous shifts across different halls. Interviews with involved nursing staff confirmed that they understood they were responsible for signing the controlled drug sheets at the beginning and end of their shifts to document that they had counted and assumed responsibility for the controlled medications. One LVN stated she had counted the controlled medications on the identified dates but could not recall why she did not sign the sheets, acknowledging that she had been trained to sign when coming on and leaving her shift. Another LVN reported that she had counted the drugs on the listed dates and attributed the missing signatures to forgetting after working double shifts, while stating that her narcotic counts had always been accurate. A third LVN similarly stated she always counted the controlled medications before taking responsibility for them but could not recall why she did not sign on the specified dates. Additional attempts to interview a medication aide and another LVN involved were unsuccessful. The DON stated that nurses and MAs were expected to sign in and out on the controlled drug sheets to ensure controlled drugs were being counted accurately and acknowledged that she and the ADON were responsible for reviewing the sheets twice weekly, but that the sheets had been overlooked while she was adjusting to her role. The Administrator also stated that all nurses and MAs were responsible for signing in and out on the controlled drug count sheets. The facility’s written policy on controlled substances required nursing staff to count controlled medications at the end of each shift, with the oncoming and offgoing nurses counting together and documenting the count, and using these records to reconcile inventory and identify loss or potential diversion. The report notes that this failure could place the facility at risk for drug diversion.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse and neglect, as evidenced by several incidents involving both staff-to-resident and resident-to-resident abuse. In one instance, a female resident with a history of cerebral infarction, schizophrenia, and hemiplegia was subjected to unwanted sexual contact by another resident, who entered her room and rubbed her leg under the covers without consent. The incident was witnessed by a hospice RN, and the resident expressed that she was upset by the event. The perpetrator had a documented history of inappropriate sexual behaviors and was cognitively intact at the time of the incident. There were also multiple cases of physical and verbal abuse perpetrated by staff members against a male resident with traumatic brain injury, dementia, and severe cognitive impairment. One CNA was observed by another staff member to have called the resident derogatory names, physically restrained him during care, and used excessive force, including pinning him against a wall and stomping on his feet. Another CNA was reported to have verbally abused the same resident and forcefully pushed him into a chair. Both incidents were substantiated by witness statements and resulted in the termination of the staff involved. Additionally, the facility failed to prevent and appropriately manage numerous resident-to-resident altercations, resulting in physical harm such as scratches, hitting, and other aggressive behaviors. These incidents involved residents with significant cognitive and behavioral impairments, including dementia, bipolar disorder, and psychotic disorders. The care plans for these residents indicated known risks for aggression and behavioral issues, yet the facility did not effectively intervene to prevent repeated episodes of abuse among residents.
Failure to Update and Implement Comprehensive Care Plans After Resident-to-Resident Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents following incidents of resident-to-resident aggression and inappropriate sexual behavior. In several cases, care plans were not updated to reflect new or recurring behavioral incidents, nor were interventions added to prevent further occurrences. For example, after an incident where a male resident inappropriately touched a female resident, the care plan for the perpetrator did not include specific interventions to prevent further sexual abuse episodes, despite documentation of the event and its investigation. Additionally, care plans for residents who were either aggressors or victims in multiple resident-to-resident altercations were not revised to address their changing needs. One resident with a history of physical aggression was involved in several incidents with other residents, resulting in scratches, skin tears, and emotional distress. Despite these events, the care plans for both the aggressor and the victims were not promptly or adequately updated to include new interventions or strategies to mitigate future risks or address the impact of the incidents. The deficiency was further compounded by a lack of verification and follow-through in the care plan update process. The administrator acknowledged that while requests to update care plans were communicated via email to the MDS contractor, there was no system in place to ensure these updates were completed. This breakdown in communication and oversight resulted in care plans that did not accurately reflect the residents' current needs or the interventions required to ensure their safety and well-being, as evidenced by repeated incidents and confirmed findings in the facility's own investigations.
Removal Plan
- Resident #1's care plan was updated; psych NP discontinued Buspirone 5 mg with new order for Buspirone 20 mg every evening.
- Resident #2, #3 and #5 care plans updated regarding receiving abuse
Failure to Timely Report Alleged Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator and within the required two-hour timeframe to the administrator and state authorities. In one instance, a staff member witnessed a certified nursing assistant verbally and physically abuse a male resident with traumatic brain injury, dementia, and other cognitive impairments. The staff member did not report the incident immediately, only disclosing it during an unrelated investigation approximately 1.5 weeks later. The abuse coordinator became aware of the incident during staff interviews, and the administrator did not report the new allegation to the state as a separate event. In another case, a licensed vocational nurse failed to report an allegation of abuse involving two residents engaged in a physical altercation. The nurse documented the incident but did not notify the administrator or director of nursing as required. The director of nursing only became aware of the incident upon reviewing progress notes the following day. The nurse involved stated she was not present during the incident and did not recall being trained to report abuse immediately to the administrator. A third incident involved a delay in reporting a resident-to-resident altercation where one resident scratched and pulled another resident's hair, resulting in a visible injury. The administrator was not informed of the incident until the following day, after the resident reported it and showed the injury. The administrator acknowledged that the allegation was reported late and that all abuse allegations are required to be reported to state agencies within two hours of the incident. These failures were identified through observations, interviews, and record reviews, and were found to place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
Failure to Maintain Clean, Safe, and Functional Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, functional, and comfortable environment for residents in several rooms, as evidenced by the presence of dead bug carcasses and dead cockroaches in resident bathrooms and vanities. Observations revealed missing baseboards, stained caulk and flooring, cracked and missing tiles, and a bathroom vanity with missing doors. Multiple residents confirmed that while housekeeping staff cleaned their rooms, the bathrooms were not cleaned properly, and dead cockroaches were not removed. Residents also reported that the bathroom tiles had been falling off for some time. Interviews with facility staff, including the Administrator, Maintenance Director, and Housekeeping Supervisor, revealed a lack of awareness regarding the physical plant issues and the presence of pests. The Maintenance Director and Administrator both acknowledged the observed deficiencies during walkthroughs but stated they had not received any maintenance requests for the repairs. The Housekeeping Supervisor admitted that bathrooms and vanities were not cleaned as thoroughly as required and that there was no cleaning checklist or follow-up to ensure proper cleaning. Staff indicated that maintenance requests were supposed to be logged at the nurse station, but no such requests had been made for the observed issues. A review of facility policies indicated that the maintenance department is responsible for keeping the building in good repair and free from hazards, and that staff are expected to provide a clean, sanitary, and homelike environment. Despite these policies, the observed conditions in the resident rooms and bathrooms did not meet these standards, as evidenced by the lack of cleanliness, unrepaired damage, and unaddressed pest issues.
Failure to Maintain Proper Hand Hygiene During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to adhere to proper hand hygiene protocols while providing incontinent care to a resident with multiple comorbidities, including diabetes mellitus type 2, severe obesity, and moderate cognitive impairment. During the observed care, both CNAs wore gowns and gloves, but after cleaning the resident, one CNA did not perform hand hygiene after changing gloves or when transitioning from dirty to clean supplies. The other CNA, after removing a soiled brief and cleaning the resident, touched clean linens and adjusted a clean brief without changing gloves or performing hand hygiene. Both CNAs only completed hand hygiene after the care was finished and gloves were removed. Interviews revealed that one CNA acknowledged the need for hand hygiene after glove changes and when moving from dirty to clean, as trained by the facility, but apologized for not having hand sanitizer available during care. The other CNA was unclear about the specific requirements for hand hygiene after glove changes or when moving from dirty to clean, stating she was not trained in those aspects. The Director of Nursing confirmed that infection control in-services were conducted regularly and that staff were expected to follow the hand hygiene policy, which requires hand hygiene before and after resident contact, between glove changes, and after soiled hands. Facility policy and recent in-service documentation supported these requirements.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Accurately Complete MDS Assessment for Resident with Multiple Diagnoses
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment reflective of their current status, specifically regarding the completion of the Minimum Data Set (MDS) assessment. Record review showed that the resident, a male with multiple complex diagnoses including quadriplegia, diabetes, chronic kidney disease, neurogenic bladder, and major depressive disorder, had an MDS assessment that did not include several of his active diagnoses such as coronary artery disease, neurogenic bladder, quadriplegia, or depression. The resident was cognitively intact, used a wheelchair, and was dependent for most activities of daily living (ADLs). Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for the accuracy and completion of the MDS. The DON stated that although her signature appeared on the MDS, she could not verify it and was not informed she should review the MDS for accuracy. The Administrator and VPO both indicated that the facility did not have a current MDS Coordinator at the time, and that oversight was expected from either the DON or a Regional MDS Coordinator, who had also recently been terminated. The facility did not have a specific MDS policy and relied on the RAI manual. This lack of accurate assessment and clear responsibility could result in residents not receiving appropriate care and services.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Sanitary Environment and Functional Resident Furnishings
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents in rooms 217 through 224, as evidenced by persistent foul odors in the hallway and in front of specific rooms. Observations revealed a strong smell of urine, feces, and body odor throughout the hallway, with the odor being most pronounced in front of one room. The odor was present at multiple times during the day, despite the presence of housekeeping staff and repeated cleaning efforts. Interviews with staff and residents confirmed that some residents refused hygiene care and bathing, contributing to the ongoing odor issue. Housekeeping staff reported cleaning certain rooms multiple times daily and using specific chemicals to address the odor, but the problem persisted, particularly in rooms where residents refused showers. Additionally, a dresser in one resident's room was found to be in disrepair, with multiple broken or missing handles and drawers that would not close properly. The resident reported that the dresser had been broken for several months and expressed frustration about the situation. The Maintenance Director stated that maintenance issues were addressed as reported, but there was no record of the broken dresser being reported. The administrator confirmed that a replacement dresser had been ordered but had not yet arrived, resulting in the continued use of the damaged furniture. These deficiencies were observed to negatively impact the quality of life and comfort of the residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in multiple resident rooms being infested with cockroaches and spiders. Observations by surveyors revealed live and dead cockroaches in several rooms, including instances where cockroaches were seen running across furniture, breakfast trays, and restroom sinks. Spiders, both live and dead, were also found in resident rooms. Residents expressed distress about the presence of pests, with one resident stating that the cockroaches made her feel terrible and another reporting roaches on her breakfast tray. Staff interviews confirmed that pests were seen occasionally, with sightings of flies and cockroaches occurring a couple of times a month. The facility maintained a pest control log and had a contract with a pest control company to spray monthly and as needed, with additional treatments in certain months. Staff were instructed to report pest sightings in a binder at the nurses' station, and plastic containers were provided to residents who kept food in their rooms to help limit pest issues. Despite these measures, maintenance records and pest control logs documented ongoing reports of roaches in specific rooms over the preceding months. The facility's policy required maintaining an effective pest control program to keep the building free of insects and rodents, but observations and records indicated that this standard was not met for several residents.
Failure to Resolve Resident Grievances Regarding CNA Assignments
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident who expressed dissatisfaction with certain CNAs providing her care. The resident, who was cognitively intact and able to communicate her needs, had a history of mental health conditions including dementia, anxiety, schizophrenia, and bipolar disorder. She repeatedly voiced grievances about not wanting specific CNAs, identified as CNA A and CNA B, to enter her room or provide care, citing reasons such as improper care and feeling unsafe. Despite the resident's grievances being documented, the facility did not take adequate action to address her concerns. The grievances were not thoroughly investigated, and there was a lack of communication among staff regarding the resident's preferences. The facility's staffing sheets indicated that CNA A and CNA B continued to be assigned to the resident on multiple occasions, contrary to her expressed wishes. Interviews with staff revealed a lack of awareness and communication about the resident's grievances, with some staff members unaware of the resident's requests or the grievances filed. The facility's grievance policy required immediate action to resolve complaints, but this was not adhered to in the case of the resident. The failure to address the resident's grievances could lead to unresolved issues and a decreased quality of life for the resident. The facility's leadership, including the DON and the grievance official, were not fully informed or proactive in resolving the resident's concerns, resulting in continued dissatisfaction and anxiety for the resident.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 24 out of 45 days reviewed. This deficiency was identified through interviews and record reviews, which revealed that there were no RN hours recorded on several specific dates, and on some days, the RN hours were less than the required 8 hours. The facility's records indicated that there were 4 RNs employed, but the facility struggled with staffing issues, including hiring a Director of Nursing (DON) and ensuring consistent RN coverage. Interviews with the Human Resources representative, the DON, and the Administrator highlighted the staffing challenges faced by the facility. The HR representative acknowledged the missing RN hours and the difficulty in hiring RNs. The DON, who started in November, confirmed the lack of sufficient staff to provide the required RN coverage before her tenure and emphasized the importance of adhering to the policy. The Administrator also acknowledged the staffing issues and the potential impact on resident care due to inadequate RN coverage. The facility's policy mandates that an RN must be onsite for 8 consecutive hours daily, which was not consistently met during the review period.
Failure to Submit Staffing Information to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for two of the three quarters reviewed, specifically for Quarter 2 and Quarter 3 of 2024. This deficiency was identified through interviews and record reviews, which revealed that the facility did not submit the required Payroll-Based Journal (PBJ) reports for these periods. The failure to submit these reports was attributed to a lack of oversight and responsibility confusion among the staff. The Regional Director of Clinical Operations was identified as the person responsible for submitting the PBJ reports, but it was discovered that a third-party company previously tasked with this responsibility had not been submitting the reports, leading to the termination of their contract. Interviews with various staff members, including the HR, the Regional Director of Clinical Operations, the Director of Nursing (DON), the Administrator, and the Corporate HR, highlighted a lack of awareness and education regarding the submission process. The HR mentioned that the staff clock in and out, and the system logs the times, but the PBJ reports were not submitted due to oversight. The Regional Director of Clinical Operations and the Corporate HR both acknowledged that they were not aware of the need to check if the reports were submitted. The facility's policy on reporting direct-care staffing information was not followed, resulting in the failure to submit the PBJ reports timely, which could affect the facility's ability to take credit for the staff present and potentially impact the quality of care provided.
Facility Fails to Maintain Safe Operating Condition of Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as observed during a survey. The gas stove in the kitchen had three burners that would not ignite, and there was a black buildup on the griddle next to the burners. The walk-in freezer had a loose and hanging door gasket, with icy frost and frozen liquid on the floor. Additionally, the milk box had a loose gasket with mildew. These issues were acknowledged by the Dietary Manager (DM) and Maintenance Director (MD), who were unaware of the severity of the problems. In a resident's room, an electric bed was found with a spliced electrical cord, exposing live wires without proper insulation or a connection box. The Administrator expressed that the electric beds should be in good working condition and noted that staff had not reported the unsafe wiring. The facility's Maintenance Service policy indicates that the Maintenance Department is responsible for ensuring all equipment is safe and operable, which was not adhered to in these instances.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. Baking sheets, pans, and skillets were found with dark-colored buildup on both the inside and outside surfaces, indicating they were not properly cleaned. Additionally, food items in the walk-in cooler were not managed according to professional standards. A container of pureed food was found with an unreadable label and was past its use-by date, while another container of fruit lacked any labeling. These lapses in food storage and labeling could potentially lead to foodborne illnesses among residents. Furthermore, the facility did not ensure that the sanitizing solution used for cleaning kitchen surfaces was at the correct concentration. A red bucket of sanitizing solution was found to have less than 50 ppm of chlorine, indicating it was ineffective. The chlorine solution container was not connected to the dispenser, which is used to fill the sanitizing bucket. These deficiencies were in violation of the facility's own policies and the 2022 Food Code, which require proper labeling, cleaning, and sanitizing practices to prevent contamination and ensure food safety.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in several areas, including Hall 200, the dining room, and specific resident rooms. Observations revealed that door frames in Hall 200 were not intact, with missing paint and wood pieces, and the floor tiles were discolored with a buildup of glue, paint, and debris. The exit corridor to the smoking area had six missing floor tiles, exposing discolored concrete. In the main dining room, there was a buildup of old paint and dried glue along the back wall, and a missing tile near the door created a floor level difference. An unlocked closet labeled for oxygen storage was found empty, with walls covered in a black fuzzy substance, a white substance on the door, and spider webs with sacs, emitting a smell of wet dirt. Additionally, specific resident rooms were not properly maintained. One room had a 6-inch base trim detached from the wall and lying on the floor for approximately 5 feet. Another room had a beige substance splattered on the ceiling and curtains with rips along the bottom. Interviews with the maintenance director and the administrator revealed acknowledgment of these issues, with the maintenance director admitting to never opening the problematic closet and the administrator confirming the need for repairs but lacking documented plans for such actions. The facility's maintenance service policy indicated that the maintenance department is responsible for keeping the building safe and operable at all times.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and allowed unauthorized access to medication, specifically affecting one resident. During an observation, a 30-cc medicine cup containing approximately 20 cc of white powder was found on the nightside table next to the resident's bed. The resident, who was cognitively intact and had diabetes, stated that the powder was not her medication and was unaware of how it got there. The powder was identified as nystatin powder, which was prescribed to be applied to the resident's abdominal folds for yeast treatment. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that the medication should not have been left in the resident's room and should have been stored in the medication cart when not in use. The ADON confirmed that nurses were responsible for ensuring medications and treatment items were not left in resident rooms. The Administrator stated that her expectation was for nurses to keep medications within their eyesight and not leave them at the bedside, indicating a lapse in following proper medication storage protocols.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure the safety and protection of two residents from sexual abuse. On June 15, 2024, an incident occurred in the dining room where one resident, who has moderate intellectual disabilities and is non-verbal, was observed performing oral sex on another resident. The first resident has a history of inappropriate sexual behaviors and is severely cognitively impaired, as indicated by a BIMS score of 03. The second resident, who has a BIMS score of 10 indicating moderate cognitive impairment, did not exhibit any behaviors over the previous seven days. Both residents were known to have inappropriate sexual behaviors and were at risk for further episodes. The incident was witnessed by another resident, who reported it to the staff. The staff responded by separating the involved residents and notifying the appropriate authorities, including the police. The second resident, who was on parole, was noted to have been in a motorized wheelchair and did not attempt to remove himself from the situation. The police were involved, and statements were taken from the residents involved. The facility's records indicate that the second resident was aware of the incident and expressed a desire to have it documented by the police. The facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse, as both residents involved had documented histories of inappropriate sexual behavior. The facility's care plans for both residents included interventions to manage these behaviors, but the incident still occurred, indicating a lapse in the implementation of these interventions. The facility's policy on abuse and neglect emphasizes the importance of preventing such incidents, but the occurrence of this event suggests that the policy was not effectively enforced at the time.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency within the required 2-hour timeframe for four residents. In the first incident, Resident #4, who has a history of behavioral issues and cognitive impairment, verbally and physically assaulted Resident #5. Despite the incident being documented by an LVN, the facility did not notify the State Agency within the mandated period. Resident #4 was later transferred to a behavioral center for further management of his behavior. In the second incident, Resident #6, who suffers from severe cognitive impairment and mental health issues, physically assaulted Resident #7 after a minor altercation involving a wheelchair. The incident was documented, and both residents were assessed for injuries, but the report to the State Agency was delayed beyond the required 2-hour window. Resident #6 was subsequently transferred to a behavioral hospital for further evaluation and treatment. Interviews with facility staff, including the ADON and the Administrator, revealed that there was a lack of immediate reporting to the Abuse Coordinator, which contributed to the delay in notifying the State Agency. The facility's policy mandates immediate reporting of abuse allegations to the Administrator or their designee, but this protocol was not followed, resulting in the deficiency.
Failure to Implement PASRR Service Plan for Resident
Penalty
Summary
The facility failed to implement the PASRR comprehensive service plan for a resident who was reviewed for PASRR assessments. The resident, a male with diagnoses including schizoaffective disorder, cerebral palsy, dysphagia, and aphasia, was admitted to the facility and was identified as PASRR positive for intellectual disability. The PASRR Comprehensive Service Plan recommended specialized occupational therapy, physical therapy, and speech therapy, which were not provided within the required timeframe. The Director of Rehabilitation indicated that therapy evaluations were submitted but not authorized, resulting in a delay in the initiation of therapy services. The Regional Director of Reimbursement confirmed that the facility did not meet the PASRR requirements, which mandate that specialized services be requested and initiated within specific timeframes. The resident did not receive the agreed-upon therapy services through PASRR until several months after the initial PCSP and IDT meeting. The Administrator, who was not present during the initial meeting, acknowledged the potential negative outcomes of not meeting PASRR timeframes. The facility's policy indicated that they should coordinate services per state policy and develop a care plan addressing specific needs when special services are required.
Failure to Protect Residents from Abuse Due to Inadequate Monitoring and Reporting
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving inappropriate sexual behavior by a resident with dementia and other mental health conditions. The resident, who had a history of inappropriate sexual behaviors, was involved in two incidents where he touched the breasts of two different female residents. The first incident occurred in the dining room, where the resident grabbed another resident's breast and made lewd comments. Despite being redirected and sent for a psychiatric evaluation, the resident returned to the facility without increased monitoring. In the second incident, the same resident was observed touching another female resident's breast while reaching for a coloring book. The staff separated the residents and initiated behavioral monitoring, but there was no documentation of continued monitoring after a certain period. The facility's care plan for the resident did not reflect the incidents, and there was a lack of incident reporting and proper documentation. Interviews with staff revealed inconsistencies in awareness and reporting of the incidents. Some staff were unaware of the resident's behaviors and the need for close monitoring. The facility's policy on abuse and neglect was not effectively implemented, as evidenced by the lack of immediate separation of residents and inadequate monitoring of the aggressor. The facility's failure to protect residents from abuse and ensure proper documentation and reporting led to the identification of an Immediate Jeopardy situation.
Removal Plan
- R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors.
- R1 will remain on q 15-minute checks until IDT team meets and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors.
- Charge nurse/nurse managers assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found.
- Administrator/abuse coordinator reeducated all staff 100% completion on Abuse & Neglect policy for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test.
- Staff were reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur.
- Staff were reeducated to stay with the aggressor one-on-one until further instruction from the abuse coordinator and/or until the evaluation or further intervention.
- The Administrator reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation.
- Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached.
- MDS nurse reviewed and updated care plan to reflect sexually inappropriate behaviors.
- The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC).
- Administrator/and or designee will reeducate floor staff to review Kardex in PCC (EHC) for updated interventions for each resident.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified in the cases of two residents who were subjected to inappropriate sexual behavior by another resident. The incidents involved a resident with a history of inappropriate sexual behaviors, who was not adequately monitored or managed according to the facility's policies. In one incident, a resident with dementia and other cognitive impairments was observed grabbing the breast of another resident in the dining room. Despite the resident's known history of inappropriate sexual behavior, the facility did not implement sufficient monitoring or interventions to prevent further incidents. The staff failed to maintain one-on-one monitoring or update care plans to reflect the resident's behaviors, which were necessary steps outlined in the facility's abuse and neglect policy. Another incident involved the same resident inappropriately touching a different resident's breast. The staff's response was inadequate, as they did not initiate one-on-one monitoring or update the care plans to address the behavior. The facility's failure to follow its own policies and procedures for preventing and addressing abuse and neglect placed residents at risk of further harm.
Removal Plan
- R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors.
- R1 will remain on q 15-minute checks until IDT team meets and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors.
- Charge nurse/nurse managers assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found.
- Administrator/abuse coordinator in-service all staff 100% completion on Abuse & Neglect policy for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test.
- Staff were reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This education included protecting and/or removing the resident from the situation, as well as who the abuse coordinator is, when to report, and how to report abuse.
- Staff were reeducated to stay with the aggressor until further instruction from the abuse coordinator and/or until the evaluation or further intervention.
- The Administrator reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation.
- Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached.
- MDS nurse reviewed and updated care plan to reflect sexually inappropriate behaviors.
- The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC).
- Administrator/and or designee will reeducate floor staff to review Kardex in PCC (EHC) for updated interventions for each resident.
Deficiency in Nursing Leadership and RN Coverage
Penalty
Summary
The facility failed to ensure compliance with federal guidelines requiring a full-time Director of Nursing (DON) and registered nurse (RN) coverage for 8 consecutive hours, 7 days a week. The deficiency was identified through interviews and record reviews, revealing that the facility did not have a full-time DON from August 16, 2024, to September 30, 2024. Additionally, there was a lack of RN coverage on multiple days throughout September 2024, specifically on September 16, 17, 18, 19, 20, 23, 24, 25, 26, 27, and 30. These lapses in staffing could potentially place residents at risk due to insufficient nursing oversight and care. Interviews with the facility's Administrator and RNC T highlighted a lack of awareness and communication regarding staffing requirements and the use of agency staff to fill RN positions. The Administrator admitted to not knowing that agency nurses could be used for RN coverage until late September 2024. Furthermore, the facility did not have a policy in place for ensuring DON or RN coverage, relying instead on federal guidelines. The absence of a DON and RN coverage was attributed to the medical records staff handling scheduling, whose last day was September 20, 2024, and the facility's ongoing recruitment efforts for a new DON.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner documented their rationale for extending the order in the resident's medical record. This deficiency was observed in three residents who were receiving PRN anti-anxiety and antipsychotic medications without a documented stop date or justification for continuation beyond 14 days. The lack of proper documentation and monitoring could lead to residents receiving unnecessary medications and not achieving the intended therapeutic benefits. Resident #1, who had a history of dementia, delusional disorder, and major depressive disorder, was prescribed Ativan both orally and via injection for anxiety and agitation. Despite receiving the medication multiple times, there was no documentation of a stop date or monitoring of behaviors as required. The pharmacy had recommended discontinuation or justification for continuation, but the facility deferred the decision to the psychiatry team without proper follow-up. Additionally, there were no consent forms for Ativan in the resident's records. Similarly, Resident #2, diagnosed with schizoaffective disorder and dementia, received PRN Ativan injections without a pharmacy review or documented stop date. Resident #3, with diagnoses including dementia and anxiety, also received Lorazepam without a stop date or documented rationale for continuation. Interviews with facility staff revealed a lack of awareness and understanding of the requirement for a 14-day stop date for PRN psychotropic medications, as well as inadequate monitoring of residents' behaviors and side effects.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse involving two residents to the State Survey Agency within the required two-hour timeframe. The incidents involved a resident with a history of inappropriate sexual behaviors, who was reported to have touched the breasts of two female residents on separate occasions. Despite the facility's policy requiring immediate reporting of such allegations, the incidents were not reported to the state agency, potentially placing residents at risk of abuse, physical harm, mental anguish, and emotional distress. The first incident occurred when a resident with dementia and other cognitive impairments was reported to have inappropriately touched another resident's breast in the dining room. The staff attempted to redirect the resident and contacted the medical director, who prescribed medication for agitation. The resident was monitored and eventually sent to a behavioral hospital for evaluation. However, there was no incident report completed, and the state agency was not notified of the sexual abuse allegation. In the second incident, the same resident was reported to have touched another female resident's breast. The staff separated the residents and initiated behavioral monitoring, but again, the incident was not reported to the state agency. Interviews with staff revealed a lack of clarity and communication regarding the reporting process, with some staff members unaware of the requirement to report such incidents within two hours. The facility's failure to report these allegations as required by federal guidelines highlights a significant deficiency in their abuse prevention and reporting procedures.
Failure to Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for five residents, leading to significant weight loss and lack of appropriate dietary interventions. The report highlights that the facility did not offer therapeutic diets when ordered by healthcare providers, nor did it have systems in place to monitor weight changes effectively. This deficiency was observed in all five residents reviewed for weight loss and nutrition. Resident #1 experienced a significant weight loss of 47 lbs. over one month, 51 lbs. over three months, and 49 lbs. over six months. Despite having a care plan that included monitoring appetite and weight, there were no specific care plans addressing weight loss. The resident frequently refused meals, and there was no documentation of dietary supplements being offered. Interviews with staff revealed a lack of awareness regarding the resident's nutritional needs and the absence of communication with the physician about the resident's weight loss. Similar issues were noted with Residents #2, #3, #4, and #5, who all experienced significant weight loss without appropriate dietary interventions or physician notifications. The Registered Dietician's recommendations for supplements and dietary changes were not implemented, and there was a lack of communication between the dietician, nursing staff, and physicians. The facility's policy on weight assessment and intervention was not followed, contributing to the residents' continued weight loss and potential health decline.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper management of a central line dressing for a resident. The resident, a male with a history of cellulitis, hypertension, diabetes, and Charcot's joint syndrome, had a physician's order for the dressing of his PICC line to be changed every seven days. However, observations revealed that the dressing had not been changed since the resident's admission, which was confirmed by the resident himself. Interviews with the medical director, administrator, and nursing staff indicated a lack of adherence to the dressing change schedule, which is crucial for preventing infections. Additionally, the facility's treatment nurse demonstrated inadequate hand hygiene practices during wound care for the same resident. The nurse failed to change gloves and perform hand hygiene between glove changes, after picking up an item from the floor, and before and after entering the resident's room. These actions were observed during wound care procedures, where the nurse used the same piece of gauze for multiple incisions and did not follow proper hand hygiene protocols. The medical director and director of nursing acknowledged these lapses and emphasized the importance of hand hygiene in preventing the spread of infections. The facility's policies on infection control, central venous catheter dressing changes, and hand hygiene were not followed, contributing to the deficiencies observed. The policies outlined the necessity of regular dressing changes and proper hand hygiene to prevent infections, yet staff interviews and observations indicated a lack of compliance. The treatment nurse's actions, such as not changing gloves between treating different wound areas and leaving the room without performing hand hygiene, further highlighted the facility's failure to adhere to its own infection control protocols.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, a male with multiple diagnoses including cellulitis, hypertension, diabetes, and Charcot's joint syndrome, was admitted to the facility but did not have a baseline care plan in place. This omission was identified during a record review, which showed no baseline care plan available for the resident. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator confirmed that a baseline care plan should have been completed upon admission to guide the care provided to the resident. The MDS Coordinator acknowledged that the baseline care plan was supposed to be triggered upon admission, but it either did not trigger or was deleted. The DON and Administrator both emphasized the importance of baseline care plans as a framework for staff to understand and provide the necessary care to maintain the resident's quality of life. The facility's policy, revised in December 2016, mandates that a baseline care plan be developed within 48 hours of admission to ensure the resident's immediate care needs are met. The failure to adhere to this policy could place newly admitted residents at risk of receiving inadequate care and services.
Failure to Maintain and Revise Resident Care Plan
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for a resident. Specifically, the care plan for a resident was closed erroneously on a date in December, despite the resident not being discharged. This oversight resulted in the care plan not being updated or revised quarterly as required. The resident, who was readmitted to the facility with multiple diagnoses including dementia, blindness, heart disease, schizoaffective disorder, hypertension, bipolar disorder, and Parkinson's disease, was severely cognitively impaired and required substantial assistance with activities of daily living. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the care plan should have been active and revised quarterly, as well as after any significant change in the resident's condition. The MDS Coordinator acknowledged the error and noted that the care plan should have been revised in March and June, but these revisions were not completed due to the care plan being closed. The facility's policy mandates that comprehensive, person-centered care plans be developed within seven days of the completion of the required comprehensive assessment and revised as the resident's condition changes, at least quarterly, and upon readmission from a hospital stay.
Failure to Provide Contracture Management for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion (ROM) and mobility issues, specifically neglecting to assess and provide necessary equipment such as hand rolls or positioning devices. This deficiency was identified for a resident who had multiple diagnoses, including epilepsy, mood disorder, intellectual disabilities, and functional quadriplegia, among others. Despite these conditions, the resident's annual assessment noted no impairment in ROM, and there was no care plan or interventions related to her contractures. The resident's occupational therapy (OT) assessment indicated severe flexed contractures in the right upper extremity, poor sitting balance, and decreased ROM, yet she was discharged from OT services due to lack of a payer source without recommendations for a hand roll or positioning device. Observations revealed that the resident's right hand was contracted, with long nails and debris between the fingers, and no roll or brace was provided. Interviews with facility staff, including the Director of Nursing (DON) and the Rehabilitation Director, revealed a lack of awareness and documentation regarding the resident's need for contracture management. The facility's policies on joint mobility and rehabilitative nursing care outlined the need for assessments upon admission and regularly thereafter, as well as the implementation of a restorative program to prevent deterioration of joint mobility. However, these protocols were not followed for the resident in question, leading to a failure in providing necessary care and services to maintain her highest level of well-being. The deficiency was further compounded by the absence of documentation and communication among staff regarding the resident's needs and the lack of a structured plan for contracture management.
Improper Discharge and Readmission Denial
Penalty
Summary
The facility failed to comply with discharge requirements for a resident diagnosed with schizophrenia, persistent mood disorder, and requiring a gastrostomy tube. The resident was initially transferred to a behavioral hospital after an incident where she placed a pillow over her roommate's face. Despite a 30-day discharge notice being issued, the facility did not allow the resident to return after treatment at the behavioral hospital, citing safety concerns and lack of available space in the secure unit. The facility's administrator and staff, including the DON and ADON, were involved in the decision not to readmit the resident before the 30-day notice period ended. The resident was sent back to the facility from Behavioral Hospital B, but the administrator instructed staff not to accept her, leading to her being taken to another hospital. Interviews with staff and the resident's responsible party revealed that the facility had already given the resident's bed to another individual and blocked communication with the resident's family. The resident was left at a local hospital, where she displayed no aggressive behaviors and was described as having childlike behaviors. The facility's actions were contrary to their policy, which requires a 30-day written notice for discharge. The ombudsman confirmed that the facility discharged the resident before the notice period ended, and efforts were being made to find alternative placement for the resident.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to adhere to its written policy regarding the readmission of residents following hospitalization or therapeutic leave, specifically in the case of a resident who was hospitalized for behavioral issues. The resident, who had a history of schizophrenia, persistent mood disorder, and required a gastrostomy tube, was initially admitted to the facility in July 2022. After an incident where the resident placed a pillow over a roommate's face, she was transferred to a behavioral hospital. Despite a 30-day discharge notice being issued, the facility did not allow the resident to return before the notice period ended, citing safety concerns and lack of available space in the secure unit. The facility's administrator and staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), were involved in the decision not to readmit the resident. The administrator stated that the behavioral hospital had discharged the resident prematurely, and the facility had already assigned her bed to another resident. The DON and ADON confirmed that they were instructed by the administrator not to accept the resident back, even though the effective date of the discharge notice had not yet passed. The resident was subsequently taken to another hospital after vomiting in the van outside the facility. Interviews with various parties, including the resident's responsible party, the case manager at the hospital, and the ombudsman, revealed that the facility had blocked communication with the resident's family and had not returned calls. The resident was on a waiting list for a state mental hospital, and the facility was working to secure her placement there. However, the premature discharge and refusal to readmit the resident before the 30-day notice period ended resulted in her being left at a local hospital, where she was observed to be in good spirits and without aggressive behaviors.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve resident grievances, specifically for one resident who expressed a grievance about a Certified Nursing Assistant (CNA). The resident, who was cognitively intact despite having dementia and schizophrenia, reported to a Certified Medication Aide (CMA) that she did not want a particular CNA to enter her room or provide care, citing feelings of unsafety and fear. However, the grievance was not documented or reported to the Grievance Official or the Administrator, as required by the facility's policy. The resident's care plan noted a history of confabulation, but she was able to make herself understood and understood others, indicating her grievance should have been taken seriously. Interviews with staff revealed that the grievance was known but not acted upon. The CMA acknowledged the resident's complaint but did not fill out a grievance form or notify the appropriate personnel. The CNA involved was aware of the resident's discomfort but did not report the grievance either. The Administrator and the Director of Nursing (DON) were unaware of the grievance, and the facility's grievance records showed no documentation of the resident's complaint. The facility's policy requires that grievances be documented and forwarded to the Grievance Official, but this process was not followed, leading to the deficiency.
Failure to Implement Care Plan for Aggressive Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with aggressive behaviors. The resident, who was diagnosed with encephalopathy, dementia, psychotic disturbance, mood disturbance, anxiety, and cognitive communication deficit, exhibited physical aggression towards staff members. Despite these behaviors being documented in the resident's quarterly MDS assessment, there was no care plan addressing the aggression. On a specific date, the resident exhibited aggressive behaviors, including scratching, punching, and kicking a CNA who was attempting to provide care. The CNA, who had been employed at the facility for two weeks, reported the incident to an LVN. Two other CNAs attempted to assist with the resident's care but were also met with aggression, leading them to leave the room to allow the resident to calm down. The facility's policy requires that care plans include measurable objectives and timetables to meet residents' needs, but this was not followed in this case. Interviews with facility staff, including CNAs, an LVN, and the Administrator, revealed that the omission of a care plan for the resident's aggressive behavior was a mistake. The MDS Coordinator, responsible for completing care plans, acknowledged the oversight. The Administrator emphasized the importance of including unusual or special care needs in the care plan to ensure appropriate care for residents.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for three residents reviewed for skin assessments. Specifically, the facility did not conduct weekly skin assessments for these residents, which were necessary to monitor and address potential skin integrity issues. This lapse in care was identified through interviews and record reviews, revealing that the residents were at risk of not receiving adequate care and medical interventions to maintain their health and prevent worsening conditions. Resident #1, who had multiple diagnoses including dementia, heart disease, and chronic fragile skin, was supposed to receive weekly skin assessments as per physician orders. However, there was no record of these assessments being conducted from April 10, 2024, through May 13, 2024. Similarly, Resident #2, who was at risk for skin breakdown due to conditions like cellulitis and edema, did not have weekly skin assessments documented from April 10, 2024, through May 14, 2024. Resident #3, with conditions such as hemiplegia and diabetes, also lacked documented weekly skin assessments from April 18, 2024, through May 22, 2024. Interviews with facility staff, including the Administrator and various nurses, revealed that the failure to conduct these assessments was due to a lack of scheduling and notification in the electronic record system. The previous Director of Nursing (DON) had not updated the system to reflect the new schedule for skin assessments, leading to missed assessments. Staff members indicated that they relied on electronic triggers to complete assessments and were unaware of the need to perform them without these notifications. The Administrator acknowledged the oversight and the risk it posed to residents' care.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain personal hygiene, specifically in relation to nail care. The resident, who had severe cognitive impairment and required assistance with personal hygiene, was observed with long and jagged fingernails, approximately 1/4 inch past the fingertips. The resident's care plan included interventions to ensure nails were clipped due to the risk of impaired skin integrity and self-inflicted skin tears. However, there was no documentation of nail trimming for the resident in the previous 30 days. Interviews with staff revealed a lack of awareness and documentation regarding the resident's nail care. A CNA stated that she did not notice the resident's nails being too long and could not recall when they were last trimmed. The Director of Nursing (DON) was unable to locate care sheets for nail trimming and stated that aides were expected to complete nail care for non-diabetic residents. The Administrator expressed that staff were expected to keep residents' nails trimmed to prevent potential negative outcomes such as scratches or skin tears.
Failure to Notify Physician and Responsible Party of Significant Change
Penalty
Summary
The facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for two residents. Specifically, the facility did not notify Resident #1's physician and responsible party after Resident #1 placed a pillow over Resident #2's face and said she tried to kill her. Similarly, the facility did not notify Resident #2's physician after she reported the incident involving Resident #1. Resident #1, who had diagnoses including schizophrenia, persistent mood disorder, and anxiety disorder, was admitted to the facility on a specific date. Her care plan indicated she was at risk for manic episodes and increased behaviors, and interventions included monitoring for delusions, hallucinations, and aggressive behaviors. Despite these precautions, there were no care plans related to homicidal ideations. On the day of the incident, Resident #1 admitted to trying to harm Resident #2, but the facility staff failed to notify the physician or the responsible party immediately. Resident #2, who had diagnoses including dementia with agitation, major depressive disorder, and schizophrenia, was also admitted to the facility on a specific date. Her care plan indicated she was at risk for further decline and injury due to her cognitive impairments. After the incident, Resident #2 reported feeling unsafe, but the facility staff did not notify her physician immediately. The delay in notification and lack of immediate action by the facility staff could have placed both residents at risk of further harm or decline in their health status.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents the right to be free from abuse for two residents. One incident involved a resident who self-propelled her wheelchair into another resident's room and was pulled out of her wheelchair onto the floor. The resident who pulled her out expressed frustration and used abusive language, indicating a lack of understanding of the facility's policy against physical aggression. The incident was reported, but there was no documentation of immediate corrective actions or notifications to relevant parties at the time of the incident. Another incident involved a resident placing a pillow over her roommate's face with the intent to harm. The resident admitted to trying to kill her roommate and requested to be sent to a mental institution. The incident was reported to the administrator, but there was a delay in hiring additional staff for the secure unit and in notifying the physician and responsible parties. The resident who attempted the harm was not immediately transferred to a behavioral hospital, and there was a lack of documentation in the clinical record about the incident. The facility's policies on abuse and neglect were not adequately followed, as evidenced by the lack of immediate and appropriate responses to the incidents. Staff interviews revealed inconsistencies in reporting and handling such incidents, and there was a failure to ensure the safety and well-being of the residents involved. The facility's actions and inactions led to a situation where residents were at risk of further harm and abuse.
Failure to Ensure Adequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with a history of schizophrenia, mood disorder, and anxiety disorder. This resident, who had moderate cognitive impairment, was involved in two separate incidents of aggression towards other residents. In the first incident, the resident pulled another resident out of her wheelchair after the latter entered her room. Despite this aggressive behavior, the facility did not place the resident under one-on-one supervision or move her to a private room. In the second incident, the same resident attempted to suffocate her roommate by placing a pillow over her face. Again, the facility failed to implement immediate one-on-one supervision or other safety measures to prevent further harm. The facility's response to these incidents was inadequate. The staff did not document the incidents properly, nor did they notify the physician, police, or responsible parties in a timely manner. The Director of Nursing (DON) acknowledged that the resident should have been transferred to a behavioral hospital for evaluation but failed to take immediate action. Additionally, the facility did not have a care plan in place for the resident's homicidal ideations, and there were no additional safety measures implemented to protect other residents in the secure unit. Interviews with staff revealed a lack of proper training and understanding of the facility's policies on managing aggressive behaviors. The Administrator admitted that no additional safety measures had been put in place following the incidents. Observations showed that the resident was left alone in her room without one-on-one supervision, even after the severity of her actions was known. This lack of immediate and appropriate response placed other residents at risk of physical harm and emotional distress.
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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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