Homeplace Manor Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamlin, Texas.
- Location
- 425 Sw Ave F, Hamlin, Texas 79520
- CMS Provider Number
- 675058
- Inspections on file
- 29
- Latest survey
- April 25, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Homeplace Manor Healthcare Center during CMS and state inspections, most recent first.
A resident with documented generalized anxiety disorder, panic disorder, PTSD, and depression was admitted with intact cognition and active mental health diagnoses noted in the physician progress notes and MDS. However, the PASRR Level I screening completed by the referring entity indicated no mental illness, resulting in a negative screen despite state guidance listing PTSD and severe anxiety disorder as qualifying MI diagnoses. The resident reported having these conditions and not receiving mental health services, while the MDS Coordinator and Administrator later acknowledged that the PASRR should have been positive and that the MDS Coordinator was responsible for ensuring PASRR accuracy in accordance with Texas PASRR policy.
A resident with intact cognition and diagnoses of PTSD, depression, anxiety, and panic disorder had a care plan and physician orders indicating the need for psychiatric evaluation and treatment, along with behavior and psychoactive medication monitoring. Despite this, the resident did not receive psychiatrist services; a counselor who had been visiting stopped coming and could not adjust medications, and the resident reported repeatedly requesting psychiatric care from the Social Worker and Administrator without action. The resident ultimately scheduled her own psychiatric appointment, and an LVN documented that the Administrator instructed staff to tell the resident she could not make her own appointments and must coordinate with nursing. The physician stated he had been recommending mental health services, while the Social Worker and Administrator acknowledged gaps in counseling and psychiatric services and could not provide documentation of any refusal of on-site psychiatric NP services, contrary to the facility’s behavioral health services policy.
The facility failed to follow the posted menu for a lunch meal, serving different items without notifying residents or obtaining dietician approval. A resident with dietary restrictions expressed dissatisfaction with the food quality and lack of menu communication. The dietary manager admitted the menu change was due to a delay in grocery delivery, and the administrator confirmed the dietician was not consulted.
The facility failed to maintain food safety and hygiene standards in its kitchen. Observations revealed improper storage and labeling of food items, and temperature logs for the freezer and refrigerators were not up-to-date. Additionally, a dietary staff member was not wearing a hair net due to a shortage, posing a risk of food contamination.
The facility failed to ensure that 7 out of 19 employees received mandatory effective communication training, risking resident miscommunication and social isolation. Staff interviews revealed confusion over training documentation responsibilities, exacerbated by a transition to electronic records and leadership changes.
The facility failed to provide timely training on resident rights to five staff members, including a DM, an LVN, and housekeeping staff. Record reviews showed no documentation of such training in their files, despite their employment dates ranging from August 2022 to September 2023. Interviews revealed issues with tracking and documentation due to a transition to electronic records and leadership changes.
The facility failed to provide adequate training on abuse, neglect, exploitation, and dementia care to two employees, DM and HSKP F, as revealed by missing documentation. Interviews indicated confusion over training responsibilities and a transition to electronic records, potentially placing residents at risk.
The facility failed to document infection control training for three staff members, potentially risking resident safety. Interviews revealed confusion over training responsibilities and record-keeping, with transitions to electronic records and leadership changes cited as contributing factors.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with moderate cognitive impairment. The resident did not receive a summary of the care plan, and staff interviews confirmed the absence of required documentation and discussions. This oversight could disrupt continuity of care, contrary to the facility's policy.
The facility failed to conduct annual competency evaluations for CNAs, specifically for one CNA, which could affect residents' care. The DON was responsible for these evaluations but was unavailable, and the transition to electronic records and leadership changes were cited as reasons for missing documentation.
The facility failed to properly post survey results and plans of correction in an accessible location, and included resident identifiers in the binder, potentially violating privacy rights. The administrator, responsible for maintaining the binder, did not review the contents after a resident destroyed the original documents, leading to these deficiencies.
The facility failed to maintain RN coverage for 8 consecutive hours a day, 7 days a week, for three months, missing 22 weekend days. Despite attempts to hire a weekend RN, the facility relied on a PRN RN and an Employment Service Agency for coverage. No negative outcomes were reported, but the absence of an RN could risk resident care.
A CNA failed to follow proper infection control practices during incontinence care for a resident, leading to a deficiency in the facility's infection prevention program. The CNA did not perform hand hygiene before donning gloves, failed to change soiled gloves, and did not wash hands after removing gloves, despite recent training. The facility's policy emphasizes hand hygiene to prevent infection spread.
Inaccurate PASRR Level I Screening for Resident With PTSD and Anxiety Disorders
Penalty
Summary
The facility failed to ensure the accuracy of the PASRR Level I screening for one resident with documented mental illness. The resident, an adult female admitted in November 2025, had physician-documented diagnoses of generalized anxiety disorder, panic disorder, and post-traumatic stress disorder (PTSD), with the physician progress note indicating "PTSD on multiple meds." A quarterly MDS assessment showed an intact BIMS score of 15 and listed active diagnoses of anxiety, depression, and PTSD. Despite this documentation, the PASRR Level I Screening completed by the referring entity on 11/13/2025 indicated no primary diagnosis of dementia and no indicator of mental illness, resulting in a negative PASRR screen. During interviews, the resident reported having anxiety with panic disorder, PTSD, and depression, and stated she had not received any mental health services. The MDS Coordinator acknowledged that the resident had a mental illness diagnosis and that the PASRR screening should have been positive rather than negative, and stated that a corrected screening should have been completed and sent to the local authority for evaluation. The Administrator stated she expected PASRRs to be accurate and timely, and confirmed that the MDS Coordinator was responsible for PASRR accuracy. Facility policy required following Texas PASRR policy for all mandatory meetings and care coordination, including changes that may require a change in PASRR status, and state guidance identified PTSD and severe anxiety disorder as examples of mental illness that should trigger a PASRR Evaluation when suspected.
Failure to Provide Ordered Psychiatric Services for Resident With PTSD
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate behavioral health treatment and services to a resident with PTSD, depression, and anxiety, in accordance with the resident’s assessed needs and the facility’s own policy. The resident was a cognitively intact female, independent with ADLs, with active diagnoses of generalized anxiety disorder, panic disorder, depression, and PTSD. Her care plan identified behavior problems including verbal aggression, crying, and isolation related to PTSD, depression, and panic disorder, with interventions such as administering medications as ordered, anticipating needs, providing opportunities for positive interaction, and discussing and reinforcing why behaviors were inappropriate. Physician orders included behavior monitoring, psychoactive medication monitoring, and an order for psychiatric services to evaluate and treat, along with multiple psychotropic medications for depression, anxiety, and insomnia. Despite these orders and identified needs, the resident did not receive psychiatric services as ordered. The physician progress note documented that the resident had PTSD, was on multiple medications, and “probably needs psych follow up,” and the physician later stated he had been recommending mental health services for her. The resident reported that since admission she had not received psychiatrist services, had repeatedly requested a psychiatrist for her PTSD and depression from the Social Worker and Administrator, and that a counselor who had been visiting her stopped coming; she noted that the counselor could not adjust medications and only talked with her. A progress note documented that the resident made her own appointment with a psychiatrist and that the Administrator directed staff to inform the resident she could not schedule her own appointments and must coordinate with nursing, even though the appointment had already been set. Interviews with facility staff further demonstrated the lack of appropriate behavioral health services. The Social Worker stated that the resident had been receiving counseling services but that the counselor relocated and they had not had one “in a while,” and that he only comes once a week to visit the resident. The Administrator stated that the resident had refused to see the psychiatric NP who comes to the facility since admission but was unable to produce documentation of any such refusals and acknowledged not knowing why the facility had not attempted to obtain services from a different mental health entity. The Administrator also confirmed that the resident had made her own psychiatric appointment and would be going to it. The facility’s behavioral health services policy stated that residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and that residents exhibiting emotional or psychosocial distress receive services and support addressing their individual needs, but the facility did not follow this policy for this resident.
Failure to Follow Menu and Communicate Dietary Changes
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, as observed during a lunch meal review. On the specified date, the facility did not follow the posted menu, which included baked pork chop, cheesy grits, broccoli and cauliflower, cornbread, and frosted cake. Instead, residents were served baked pork chops, mashed potatoes, a biscuit, and frosted cake. There was no substitution list available for residents to review, and the dietary manager (DM) admitted that the menu was not followed due to a delay in grocery delivery. Resident #5, who has a history of dietary calcium deficiency and other health issues, expressed a desire to know the menu in advance to make informed choices. Resident #13, who has dietary restrictions due to diabetes and other conditions, reported dissatisfaction with the food quality and lack of menu communication. The resident also mentioned that the food served did not match the dietary ticket, and substitutions were not satisfactory. The dietary manager confirmed that the menu changes were not communicated to the residents or approved by the dietician. The facility's policy requires that any menu changes be approved by the dietician and recorded on a Menu Substitution Approval Form. However, the administrator (ADMN) acknowledged that the dietician was not consulted about the menu change, and the meal served was based on resident preferences rather than nutritional guidelines. The dietician confirmed that menus should be followed and any changes should be approved, but there was no follow-up communication from the dietician before the survey exit.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The deficiencies included improper storage and labeling of food items in the freezer and refrigerator, as well as a lack of up-to-date temperature logs for these storage units. Specifically, items such as tamales, breaded meat patties, oatmeal raisin cookie dough, egg rolls, yellow cheese slices, and lettuce were found either unsealed, unlabeled, or undated. Additionally, temperature logs for the freezer and refrigerators were not maintained for the current month, which could lead to undetected spoilage if the equipment malfunctions. Furthermore, the facility did not ensure that dietary staff adhered to hygiene protocols, as one of the dietary staff members was observed not wearing a hair net while preparing and serving meals. This lapse was attributed to a shortage of hair nets in the facility. The dietary aide acknowledged the potential risk of hair contaminating food, which could deter residents from eating and potentially lead to weight loss. Interviews with the dietary manager and administrator confirmed these issues, with the administrator noting the importance of maintaining temperature logs to prevent food spoilage and the necessity of hair coverings for staff in the kitchen.
Deficiency in Staff Communication Training
Penalty
Summary
The facility failed to ensure that employees received the required training in effective communication, which is mandatory for staff members. This deficiency was identified for 7 out of 19 employees reviewed, including the Director of Nursing (DON), Maintenance (MAINT), Transport (TRNS), Certified Occupational Therapy Assistant (COTA), Dietary Manager (DM), Certified Nursing Assistant (CNA C), and Housekeeping (HSKP F). The facility did not provide evidence that the DON, MAINT, TRNS, and COTA completed the effective communication training during their orientation. Additionally, the DM, CNA C, and HSKP F did not complete the training annually as required. These lapses in training could potentially place residents at risk of miscommunication and social isolation. Interviews with staff revealed a lack of clarity and accountability regarding the tracking and documentation of training completion. The TRNS and MAINT stated they completed the training but could not provide documentation. The DM and HSKP F were unsure of who was responsible for maintaining training records. The COTA mentioned that her records had not been transferred from a sister facility. The facility's recent transition from paper to electronic records and changes in leadership were cited as contributing factors to the lack of documentation. The HR director, who was also the Business Office Manager, acknowledged the requirement for training but was unaware of how to locate the missing records.
Deficiency in Staff Training on Resident Rights
Penalty
Summary
The facility failed to ensure that five staff members, including a Dietary Manager (DM), a Licensed Vocational Nurse (LVN G), and three housekeeping and transport staff (HSKP E, TRNS, and HSKP F), received the required training on resident rights in a timely manner. This deficiency was identified through interviews and record reviews, which revealed that the employee files of these staff members did not contain any record of training on resident rights. The hire dates for these staff members ranged from August 2022 to September 2023, yet there was no documentation of the required training in their files. Interviews conducted with staff members and facility leadership highlighted issues with the tracking and documentation of training. The DM mentioned that training was conducted online, but he was unaware of how incomplete training could affect residents. The Certified Registered Nurse (CRN) and the Assistant Director (AD) indicated that a recent transition from paper to electronic records and changes in leadership contributed to the lack of documentation. The CRN also noted that the Human Resources Director was responsible for tracking completed training, but the AD, who also served as the HR Director, was unable to locate the missing records.
Deficiency in Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to provide adequate training to their staff on critical topics such as abuse, neglect, exploitation, and misappropriation of resident property, as well as dementia management. This deficiency was identified through interviews and record reviews, which revealed that two employees, DM and HSKP F, did not have documentation of having received this essential training. The absence of training records for these employees, who were hired in August 2022 and April 2023 respectively, indicates a lapse in the facility's staff development program. Interviews with staff members highlighted a lack of clarity and responsibility regarding training records. The DM mentioned that training was conducted online, but could not explain the impact of incomplete training on residents. HSKP F, despite claiming to have completed all required training, was unaware of who managed the training records. The CRN attributed the lack of documentation to a transition from paper to electronic records and a change in leadership. The AD, who also served as the HR Director, acknowledged the requirement for training but was unable to locate the missing records. This situation suggests systemic issues in the facility's training and documentation processes, potentially placing residents at risk of harm from untrained staff.
Inadequate Infection Control Training Documentation
Penalty
Summary
The facility failed to ensure that its infection prevention and control program was adequately implemented, as evidenced by the lack of training records for three staff members: DM, HSKP E, and HSKP F. These staff members were reviewed for training compliance, and it was found that they did not receive the required infection control training in a timely manner. The DM's employee file, with a hire date of August 3, 2022, lacked any record of infection control training. Similarly, HSKP E, hired on August 5, 2024, and HSKP F, hired on April 1, 2023, also had no records of such training in their files. Interviews conducted with the staff revealed a lack of clarity and responsibility regarding the tracking and documentation of training. The DM mentioned that training was conducted online, with notifications sent via email and group text, but could not explain the impact of incomplete training on residents. HSKP F claimed to have completed all required training but was unaware of who maintained the records. The CRN indicated that the HR director was responsible for tracking training but cited a transition from paper to electronic records and a change in leadership as reasons for the missing documentation. The AD, who also served as the HR director, admitted to not knowing where to find the missing records, acknowledging the requirement for reviews.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, which is a requirement to ensure effective and person-centered care. The resident, a male with moderate cognitive impairment, was admitted without a baseline care plan being completed or a summary provided to him or his representative. This oversight was identified during a record review and interviews with facility staff, who confirmed the absence of the required documentation and discussions. The facility's policy mandates that a baseline care plan be completed within 48 hours of admission to promote continuity of care and communication among staff, as well as to inform the resident and their representative of the initial care plan. Despite this policy, the responsible staff, including the Director of Nursing and registered nurses, did not complete the baseline care plan for the resident, which could disrupt the continuity of care. The facility's interdisciplinary team, which includes the DON, ADON, and ADMN, is expected to monitor the completion of these plans, but the reason for the oversight was not determined.
Failure to Conduct Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to conduct a performance review of each Certified Nursing Assistant (CNA) at least once every 12 months, specifically for one of the three CNAs reviewed for annual competency evaluations. This deficiency was identified during a personnel file review, which revealed that CNA C did not have a competency evaluation on file. The absence of these evaluations could potentially affect residents by placing them at risk of not receiving consistent and appropriate interventions necessary to meet their needs. Interviews conducted during the investigation revealed that the Director of Nursing (DON) was responsible for conducting and documenting nursing training and staff performance reviews. However, the DON was unavailable for an interview as they were out of state. The facility had recently transitioned from paper to electronic records and experienced a change in nursing leadership, which were cited as reasons for the missing documentation. Additionally, the Business Office Manager, who also served as the Human Resources Director, was unaware of the location of the missing records but acknowledged the requirement for these reviews.
Failure to Properly Post Survey Results and Protect Resident Privacy
Penalty
Summary
The facility failed to post the results of the most recent survey, including any plans of correction, in a place readily accessible to residents, family members, and legal representatives. During an observation, it was noted that the last survey results were placed in a binder outside the administrator's office, but the plan of corrections was missing. Additionally, the binder contained a form that identified residents by their resident identifier numbers, which could potentially violate residents' privacy rights. The administrator admitted responsibility for placing the survey results in the binder and explained that a resident had destroyed most of the pages over the weekend. In a hurried attempt to replace the information, the administrator did not review the contents provided by corporate before placing them back in the binder. This oversight resulted in the absence of the plan of corrections and the inclusion of resident identifiers, which were not supposed to be part of the publicly accessible documents.
Deficiency in RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for three months (October, November, and December 2023). This deficiency was identified through a review of the CMS' PBJ Staffing Data Report, which showed no RN coverage on Saturdays and Sundays for a total of 22 days during these months. Interviews with the HR Coordinator, Administrator, and Director of Nursing (DON) confirmed the absence of RN coverage on weekends, despite attempts to hire a weekend RN. The facility relied on a PRN RN and an Employment Service Agency to provide RN assistance if needed. The facility's policy, revised on September 28, 2023, states that it should provide sufficient nursing staff to ensure resident safety and well-being. However, the lack of RN coverage on weekends could potentially place residents at risk, as decisions requiring an RN's expertise might not be made. Despite this, the HR Coordinator, Administrator, and DON reported no negative outcomes for residents due to the absence of an RN on weekends, citing the availability of alternative resources.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nurse Aide (CNA) during incontinence care for a resident. The resident, a 91-year-old female with diagnoses including diarrhea and rash, required moderate assistance with activities of daily living and was occasionally incontinent of bladder. During an observation, the CNA did not perform hand hygiene before donning gloves, failed to change gloves after they became visibly soiled with urine and fecal matter, and did not wash hands or perform hand hygiene after removing the gloves. This lapse in infection control practices occurred despite the CNA having received infection control training two weeks prior. The facility's policy on hand hygiene, revised in January 2023, emphasizes the importance of hand hygiene in preventing the spread of infections. The policy requires handwashing with soap and water when hands are visibly soiled and after contact with residents with infectious diagnoses. It also mandates the use of an alcohol-based hand rub and performing hand hygiene before donning and after doffing gloves. The interim Director of Nursing (DON) acknowledged awareness of infection control concerns and stated that staff are expected to follow the facility's policy, which includes annual and periodic training as needed.
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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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