Kirkland Court Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Amarillo, Texas.
- Location
- 1601 Kirkland Dr, Amarillo, Texas 79106
- CMS Provider Number
- 675336
- Inspections on file
- 42
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 8 (3 serious)
Citation history
Health deficiencies cited at Kirkland Court Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple serious health conditions and on hospice care had a DNR order that was not properly completed, as the physician's signature was not dated. Staff interviews revealed confusion about responsibility for DNR documentation, and a second DNR form from hospice was also invalid due to improper witnessing by direct care staff. As a result, the resident's wishes regarding resuscitation were not properly documented.
A resident had a bed rail installed without a physician order, informed consent, or inclusion in the care plan. Staff interviews and record reviews confirmed that required assessments and documentation were not completed, despite facility policy mandating these steps for bed rail use.
A medication cart on the west wing was observed unlocked and unattended while residents were nearby. The RN responsible admitted forgetting to lock the cart, and both the ADON and ADM confirmed that this practice could allow residents to access medications not prescribed to them, in violation of facility policy.
Two residents were involved in an incident where a male resident with cognitive impairment accessed an unsecured hand saw from a maintenance closet and used it to threaten a female resident and damage her walker. The female resident, who has Alzheimer's and other mental health conditions, was left fearful and distressed. Staff confirmed the male resident obtained the saw from an unlocked area, and the facility failed to prevent this access, resulting in abuse and neglect.
Two residents with cognitive impairments were involved in an incident where one obtained a hand saw from an unlocked maintenance closet, threatened another, and damaged her walker. Staff and administration failed to promptly report or investigate the event as required by policy, and hazardous items were accessible due to an unlocked door. The incident was not addressed until surveyors intervened.
Two residents experienced significant lapses in supervision and environmental safety: one resident with impaired cognition and mobility eloped from the facility in a wheelchair while awaiting hospital transport, and another resident with dementia accessed a hand saw from an unlocked maintenance office and used it on another resident's walker, also making threats. Both incidents were confirmed by staff interviews and direct observation, highlighting failures in accident prevention and supervision.
A resident with cognitive impairment obtained a hand saw from an unsecured maintenance area, threatened another resident, and damaged her walker. Although several staff members became aware of the incident and removed the saw, the event was not reported to the administrator or state authorities within required timeframes, and no investigation was initiated until prompted by surveyors. Facility policy requiring immediate reporting and investigation of abuse or neglect was not followed.
A male resident with cognitive impairment obtained a hand saw from the maintenance office, threatened a female resident with it, and damaged her walker. Staff removed the saw but did not initiate or document a thorough investigation or report the incident as required by facility policy, and administrative staff expressed uncertainty about the need to report or investigate the event until prompted by surveyors.
A resident with cognitive impairment and on anticoagulant therapy was found with a nasal decongestant spray at bedside without authorization for self-administration, contrary to facility policy. Additionally, an LVN left a medication cart and another LVN left a treatment cart unlocked and unattended, allowing potential unauthorized access. Facility policies and staff interviews confirmed these actions were not permitted.
Surveyors found that food items in the kitchen, including dairy, meat, juices, and baked goods, were not properly labeled, dated, or stored according to facility policy and professional standards. Staff interviews confirmed that all dietary staff were responsible for these tasks, but lapses were observed throughout the kitchen, increasing the risk of serving spoiled or contaminated food to residents.
A resident with newly documented bipolar disorder and PTSD was not referred for a new PASRR Level I assessment following a significant change in status. Despite updated diagnoses and care plans indicating serious mental illness, staff did not initiate the required reassessment, and facility policy lacked guidance on re-screening for new qualifying conditions.
A resident with multiple complex medical conditions was admitted without a baseline care plan being developed or implemented within 48 hours, as required by facility policy. Staff interviews confirmed the omission and acknowledged its potential negative impact on care, with no documentation of a baseline care plan found in the EHR during the review period.
An LVN failed to disinfect a glucometer between blood glucose checks for multiple residents, despite facility policies requiring cleaning and disinfection between uses. This was confirmed through direct observation and staff interviews, which acknowledged the risk of cross-contamination and infection.
A resident with hemiplegia, hemiparesis, and kidney failure, who was assessed as requiring two-person assistance for transfers and toileting, was consistently assisted by only one staff member. Staff did not follow the care plan or review it, and the resident was unable to assist due to left-sided weakness. Leadership interviews revealed confusion about care requirements and reliance on MDS assessments, resulting in care that did not meet the resident's documented needs.
A facility failed to document an altercation between two residents in their medical records. The incident involved a cognitively impaired female resident and a male resident with paranoid schizophrenia. Despite being recorded in an incident report, the altercation was not noted in the residents' progress notes, contrary to facility policy. Staff interviews revealed that the charge nurse was overwhelmed and forgot to document the event, which could lead to staff being unaware of the incident and unable to monitor for related behavioral changes.
Two CNAs failed to use proper PPE during catheter care for a resident with an indwelling catheter and feeding tube, despite a sign indicating Enhanced Barrier Precautions. The resident had severe cognitive impairment and multiple medical conditions. Interviews revealed staff confusion about the necessity of these precautions, and the facility's policy was not consistently applied.
A resident with a history of falls and mobility issues experienced an unwitnessed fall resulting in a hip fracture. The facility failed to immediately notify the resident's family and physician, as required by policy. Attempts to contact the family were not documented until five days later, highlighting a lapse in communication and adherence to protocol.
The facility failed to store, label, and date food items in the pantry, refrigerator, and freezer, as observed during a survey. Interviews with staff confirmed that this could lead to food not being servable and potentially causing illness to residents. The facility's policy mandates proper labeling and dating of all refrigerated, ready-to-eat foods.
The facility failed to submit complete and accurate direct care staffing information to CMS for FY Quarter 1 2024 due to human error by IT Corp, who oversees multiple buildings. The facility's policy requires quarterly submission of this data.
The facility failed to provide an ongoing program of activities that met the interests and well-being of residents. Observations and interviews revealed that the Activity Director primarily offered coloring activities, which were not suitable for all residents, and the activity calendar was not accurately followed or legible. This deficiency placed residents at risk of boredom and a decline in their quality of life.
The facility failed to ensure the Activities Director (AD) was certified, despite the AD working for six months and waiting for the facility to pay for the classes. The ADM, ADON, and DON were aware of this deficiency, and staff expressed concerns about the potential negative impact on resident activities. The AD's personnel file lacked any training or certification, and a relevant policy was not provided.
The facility failed to ensure proper storage and labeling of medications, including leaving medication carts unlocked and unattended, and using expired insulin. This placed residents at risk for drug diversion, overdose, and incorrect administration.
The facility failed to maintain an effective infection prevention and control program, with multiple instances of staff not performing proper hand hygiene and glove changes during blood sugar checks, medication administration, incontinent care, and wound care. Interviews with staff confirmed these deficiencies, and facility policies were not followed.
A resident had bed rails installed without proper assessment, physician orders, or informed consent. The facility's policy on bed rail use was not followed, leading to potential safety risks.
The facility failed to ensure proper techniques in wound care, incontinent care, and medication administration via gastrostomy tube by an LVN. Observations revealed lapses in hand hygiene and glove-changing protocols, and the LVN admitted to not receiving adequate training. The facility lacked competency checkoffs for staff, contributing to these deficiencies.
A facility failed to ensure residents were free from significant medication errors when an LVN administered insulin to a resident using another resident's insulin pen. The resident involved had multiple chronic conditions and required insulin as per a sliding scale. The error occurred despite the facility's policies on medication administration and resident identification.
Failure to Ensure Proper Completion of Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was properly honored. A review of the resident's records revealed that a Do Not Resuscitate (DNR) order was present but was not properly completed, as the physician's signature was not dated. The paper DNR was signed and dated by the resident and two witnesses, but the physician's signature lacked a date, rendering the document incomplete. Interviews with facility staff, including the LVN, ADON, SW, and DON, confirmed that the DNR was not valid due to this omission, and there was confusion among staff regarding responsibility for ensuring the DNR was correctly completed and maintained. Further review found that a second DNR document obtained from the hospice agency was also invalid, as both witnesses were direct care staff, which did not meet the requirements outlined in the DNR instructions. The facility's policy stated that advance directives would be respected in accordance with state law and facility policy, but the documentation and staff interviews demonstrated that this was not followed in practice. The resident, who had significant medical conditions and was on hospice care, expressed her wish to be a DNR, but due to incomplete and improperly executed documentation, her wishes were not properly documented or ensured.
Failure to Obtain Consent and Document Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of bed rail use with a resident or their representative and did not obtain informed consent prior to installing a bed rail. Specifically, a one-half length bed rail was installed on the right side of a resident's bed without a physician order, without documented informed consent, and without inclusion of bed rail use in the resident's comprehensive care plan. The resident's care plan did not address bed rail use, despite the resident being identified as high risk for falls with a history of falls prior to admission. The electronic medical record and active physician orders did not contain any documentation authorizing bed rail use or consent for its installation. Staff interviews confirmed the absence of a physician order and informed consent for the bed rail, and the DON acknowledged that the lack of an order prevented the addition of bed rail use to the care plan. The facility's policy required consent and care plan documentation for side rail use, but these steps were not followed. The resident was observed using the bed rail and expressed that it made her feel safe and aided her mobility, but the required assessments, documentation, and consents were not completed as per facility policy.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that the west wing medication cart was left unlocked and unattended while unidentified residents were walking freely around it. The RN responsible for the cart returned after a short period and locked it, stating during an interview that she had forgotten to lock the cart. The RN acknowledged that leaving the cart unlocked could allow residents to take medications from it. Further interviews with the Assistant Director of Nursing (ADON) and the Administrator (ADM) confirmed that leaving medication carts unlocked could result in residents accessing and taking medications not prescribed to them. A review of the facility's medication administration policy, dated April 2019, indicated that medication carts are to be kept closed and locked when out of sight of the medication nurse or aide. The failure to follow this policy was directly observed and confirmed by staff interviews.
Failure to Prevent Resident-to-Resident Abuse and Neglect Due to Unsecured Hazardous Equipment
Penalty
Summary
The facility failed to protect two residents from abuse and neglect. One resident, a female with Alzheimer's disease, intermittent explosive disorder, psychotic disorder with delusions, and major depressive disorder, reported that a male resident threatened to cut off her foot with a hand saw and then used the saw to cut a groove into her walker. This incident was corroborated by direct observation of the damaged walker and by interviews with staff and the male resident, who admitted to both threatening the female resident and using the saw on her walker. The female resident expressed fear and distress following the incident, and her family member confirmed that she was upset and scared when recounting the event. The male resident involved had diagnoses including Parkinson's disease, unspecified dementia, major depressive disorder, anxiety disorder, muscle wasting, and muscle weakness. He was noted to have a history of being resistive to care and potentially physically and verbally aggressive due to cognitive impairment. On the day of the incident, he was able to obtain a hand saw from an unlocked maintenance closet, which he then used in the presence of other residents and staff. Staff interviews confirmed that the saw was taken from him after he was seen with it, and that he had accessed it from the maintenance office, which was not secured at the time. The facility's failure to keep hazardous equipment, such as the hand saw, secured and inaccessible to residents directly led to the incident. Staff interviews indicated that while they were trained to recognize and report abuse and neglect, the maintenance office was left unlocked, allowing the male resident to access the saw. The incident was reported to facility administration after the fact, and the female resident was left feeling unsafe and distressed as a result of the threat and the damage to her mobility aid.
Failure to Prevent and Report Resident-to-Resident Abuse Involving Hazardous Item
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not implement its abuse policy when a male resident obtained a hand saw from an unlocked maintenance closet and used it to threaten a female resident and to saw a groove into the top, front bar of her walker. The incident was not promptly reported or investigated according to facility policy, and staff responses were inconsistent and delayed. The female resident involved had a history of Alzheimer's disease with late onset, intermittent explosive disorder, psychotic disorder with delusions, and major depressive disorder. She had moderately impaired cognition and required assistance with activities of daily living. The male resident had diagnoses including Parkinson's disease, unspecified dementia, major depressive disorder, and anxiety disorder, with moderately impaired cognition but was independent in ADLs. He admitted to obtaining the saw from the maintenance area and threatening the female resident, as well as using the saw on her walker. Multiple staff members were aware of the incident, with some witnessing the male resident in possession of the saw and using it on the female resident's walker. However, there was confusion and lack of clarity among staff and administration regarding the necessity and process for reporting the incident as abuse. The maintenance closet was found to be unlocked, allowing resident access to hazardous items. The incident was not reported to the DON or state authorities in a timely manner, and no immediate investigation or protective measures were initiated until prompted by surveyor inquiry.
Failure to Prevent Resident Elopement and Access to Hazardous Items
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who had a history of cerebral infarction, aphasia, hemiplegia, and recent cranioplasty surgery, was able to elope from the facility in his manual wheelchair while awaiting transport to the hospital for severe hernia pain. Despite being identified as a wanderer with impaired cognition and requiring supervision, the resident was left unsupervised long enough to leave the building and travel half a mile to the hospital, where he was found by hospital staff. Interviews with staff and family confirmed that the resident was not wearing appropriate clothing or assistive devices and that staff were unaware of his absence until after he had left the premises. Another resident, with diagnoses including Parkinson's disease, unspecified dementia, and major depressive disorder, was able to access a hand saw from an unlocked maintenance office. This resident, who had a care plan noting potential for physical aggression and impaired cognition, was observed by staff using the saw on another resident's walker and admitted to threatening to cut off a fellow resident's foot. Staff interviews and direct observation confirmed that the maintenance office door was not consistently locked, allowing the resident to obtain the saw without restriction. The maintenance staff acknowledged the possibility of leaving the door unlocked due to being busy and in a hurry. Both incidents were confirmed through interviews, record reviews, and direct observation, demonstrating lapses in supervision and environmental safety. The facility's failure to prevent elopement and restrict access to hazardous items resulted in situations where residents were placed at risk of harm. The events were recognized as deficiencies by surveyors, with immediate jeopardy identified due to the severity of the lapses in care and safety.
Failure to Timely Report and Investigate Resident-to-Resident Threat and Property Damage
Penalty
Summary
The facility failed to immediately report and investigate an incident involving two residents, where one resident obtained a hand saw from an unlocked maintenance closet and used it to threaten another resident and damage her walker. The incident occurred when a male resident, with a history of Parkinson's disease, dementia, and behavioral issues, accessed the maintenance area and took a hand saw. He then threatened a female resident, who had Alzheimer's disease and moderate cognitive impairment, by stating he would cut off her foot and proceeded to saw a groove into her walker. Multiple staff members, including CNAs and nurses, became aware of the incident, and the saw was taken away from the resident at the time. Despite staff awareness, the incident was not reported to the facility administrator or to state authorities within the required federal timeframes. Interviews revealed that some staff reported the event to supervisors, but there was confusion and lack of clarity among the administrative team regarding the necessity and urgency of reporting the incident. The administrator and assistant director of nursing expressed uncertainty about whether the event constituted a reportable incident and did not initiate an investigation or ensure resident safety until prompted by surveyors during the inspection. Facility policy required immediate reporting of any allegations or suspicions of abuse, neglect, exploitation, or misappropriation of resident property to the administrator and appropriate authorities, with specific timeframes depending on the severity of the incident. However, the policy was not followed in this case, as the incident was not reported within the mandated two-hour or 24-hour windows, and no investigation was initiated until after surveyor intervention. This lapse was confirmed by staff interviews and review of facility records.
Failure to Investigate Resident-to-Resident Threat and Property Damage
Penalty
Summary
The facility failed to thoroughly investigate an incident involving two residents, one of whom threatened the other with a hand saw and used the saw to damage the other's walker. The incident occurred when a male resident, who had diagnoses including Parkinson's disease, unspecified dementia, and major depressive disorder, obtained a hand saw from the maintenance office. He then threatened a female resident, who had Alzheimer's disease, intermittent explosive disorder, and psychotic disorder, by stating he would cut off her foot and proceeded to cut a groove into her walker. Multiple staff members, including CNAs and an LVN, observed or were informed of the incident, and the saw was taken away from the resident by staff. Despite the seriousness of the event, there was no evidence that the facility initiated or completed a thorough investigation as required by their own policies and federal regulations. Interviews with staff revealed confusion about whether the incident needed to be reported, and some staff did not communicate the event to the appropriate administrative personnel. The administrator and ADON expressed uncertainty about the necessity of reporting or investigating the incident, and there was no documentation of an investigation or protective measures taken until surveyors began asking questions. The facility's policies require that all allegations of abuse, neglect, or exploitation be thoroughly investigated, with specific steps outlined for reviewing documentation, interviewing involved parties, and protecting residents from further harm. However, in this case, the required investigation was not conducted, and the incident was not reported in a timely manner. The lack of action persisted until the survey process prompted staff to address the situation.
Failure to Secure Medications and Prevent Unauthorized Resident Access
Penalty
Summary
The facility failed to ensure proper storage and control of drugs and biologicals as required by state and federal regulations. One resident with moderately impaired cognition and a history of anticoagulant use was found to have a nasal decongestant spray at his bedside without an order for self-administration. The resident stated he kept the medication nearby for nosebleeds, referencing a physician's recommendation, but there was no documentation in his care plan or physician orders permitting self-administration. Facility staff, including the administrator and director of nursing, confirmed that residents are not allowed to keep medications in their rooms, and policies prohibit such practices unless specifically authorized by the care team. Additionally, staff failed to secure medication and treatment carts as required. Observations revealed that a medication cart on one hall and a treatment cart on the east wing were left unlocked and unattended by LVNs while they performed other tasks. Interviews with staff acknowledged the potential for unauthorized access to these carts, and facility policy mandates that carts must be locked when not in use and never left unattended. Facility records and policies reviewed during the survey confirmed that only authorized personnel should have access to medications, and that all drugs and biologicals must be stored in locked compartments under proper conditions. The facility's own admission materials and policies reinforce these requirements, stating that medications are not allowed in resident rooms except under specific circumstances with physician orders. Despite these policies, the survey found multiple instances of non-compliance involving both resident access to medication and unsecured medication storage by staff.
Failure to Properly Store, Label, and Date Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food storage, labeling, and dating in the facility's kitchen. Specifically, items in the walk-in refrigerator, such as bags of cream, ground beef, turkeys, glasses of milk and orange juice, and an open container of cranberry cocktail juice, were found either unlabeled, undated, or past their use-by dates. In the walk-in freezer, an open box of biscuits and an unlabeled, undated bag were noted. Additionally, cookies were found on the kitchen counter in an open bag without a date. These observations were corroborated by interviews with dietary staff and the dietary manager, who confirmed that all staff were responsible for ensuring food items were properly covered, labeled, and dated, and acknowledged that failure to do so could result in serving spoiled food. A review of the facility's Food Receiving and Storage Policy indicated that all refrigerated foods should be covered, labeled, and dated with a use-by date, and that repackaged foods should be stored in sanitary containers with clear labeling. The FDA Code was also referenced, highlighting the risk of pathogen contamination and growth in improperly stored food. The facility's failure to adhere to these standards placed all residents consuming food from the kitchen at risk of cross-contamination and food-borne illness.
Failure to Complete PASRR Reassessment for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorder for a Level II PASRR review upon a significant change in status assessment. Specifically, a female resident with diagnoses of bipolar disorder and post-traumatic stress disorder (PTSD) was not reassessed with a new PASRR Level I screening, despite these qualifying diagnoses being documented after her initial admission. The original PASRR Level I assessment, completed prior to admission, indicated the resident was negative for mental illness, but subsequent records, including the MDS and care plan, reflected the presence of bipolar disorder and PTSD. Interviews with facility staff revealed a lack of understanding regarding the need for a new PASRR Level I assessment when a qualifying diagnosis is identified after admission. The DON, responsible for PASRR assessments, believed that a new screening was unnecessary if the diagnosis was presumed to be present prior to admission. The facility's policy on admission criteria did not address the need for re-screening based on new or newly identified qualifying diagnoses.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. Record reviews showed that the resident, a female with multiple complex diagnoses including hypertensive heart disease, vascular dementia, epilepsy, breast cancer, Crohn's disease, and osteoporosis, did not have a baseline care plan initiated or documented in the electronic health record under any relevant tabs. No comprehensive MDS assessments or care plans were found for the resident within the required timeframe. Interviews with facility staff, including the DON, ADON, and ADM, confirmed that a baseline care plan had not been completed within 48 hours of the resident's admission. Staff acknowledged that the absence of a timely baseline care plan could negatively impact the care provided, as it is essential for identifying and addressing the immediate needs of newly admitted residents. The facility's own policy requires a baseline plan of care to be developed within 48 hours of admission, but this was not followed in this instance.
Failure to Disinfect Glucometer Between Resident Uses
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during blood glucose monitoring for three residents. Observations revealed that LVN D performed blood glucose checks on multiple residents without cleaning or disinfecting the glucometer between uses. Specifically, after checking the blood glucose of one resident, LVN D did not clean the glucometer before using it on another resident, and this pattern was repeated with additional residents. These actions were directly observed by surveyors during their visit. Interviews with LVN D, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed awareness of the negative outcomes associated with not disinfecting equipment between residents, including the risk of cross-contamination and infection. Review of facility policies, including those on obtaining fingerstick glucose levels and blood sampling, indicated clear requirements to clean and disinfect reusable equipment between resident uses, following manufacturer instructions and infection control standards. The observed practices were not in compliance with these established policies.
Failure to Implement Two-Person Assist for Dependent Resident
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with hemiplegia, hemiparesis, kidney failure, and muscle wasting. The resident's care plan, dated 5/6/25, specified a requirement for two-person assistance with transfers, toileting, and bed mobility due to her physical limitations and risk for falls. The resident's MDS assessment also documented total dependence on staff for these activities, indicating that two or more helpers were required. Despite these documented needs, staff consistently transferred and toileted the resident with only one person. Observations confirmed that a CNA transferred the resident from bed to wheelchair and assisted with toileting alone, using a gait belt, while the resident did not assist due to left-sided weakness. Interviews with the CNA and the resident revealed that this one-person assist had been the standard practice since admission, and the CNA was unaware of the care plan's requirement for two-person assistance. The CNA admitted to not reviewing the care plan and relied on training and information from other staff. Further interviews with facility leadership, including the DON, indicated a lack of clarity regarding the resident's required assistance level and a reliance on MDS lookback periods to determine care needs. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, but these were not followed in practice for this resident, resulting in care that did not align with the resident's assessed needs.
Failure to Document Resident Altercation in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents involved in an altercation. On 12/4/2024, an incident occurred between Resident #1, a female with severe cognitive impairment due to conditions such as cerebral infarction and vascular dementia, and Resident #2, a male with intact cognition but diagnosed with paranoid schizophrenia and unspecified dementia. The altercation involved Resident #1 attempting to take a cup of juice that belonged to Resident #2, leading to an interaction that was not documented in either resident's clinical records, despite being noted in an incident report. Interviews with facility staff revealed that the incident was not documented in the residents' progress notes, which is a requirement according to the facility's policy on resident-to-resident altercations. The Assistant Director of Nursing (ADON) acknowledged the oversight and noted that the charge nurse on duty, LVN A, failed to document the incident due to being overwhelmed. The lack of documentation could lead to staff being unaware of the incident and unable to monitor for related behavioral changes, as noted by the ADON.
Inadequate Infection Control Practices During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) by two certified nursing assistants (CNAs) during catheter care for a resident. The CNAs, identified as CNA B and CNA C, did not wear the required gowns for Enhanced Barrier Precautions while performing catheter care on a resident who had an indwelling catheter and a feeding tube. This oversight was observed despite a sign on the resident's door indicating the need for Enhanced Barrier Precautions, which include wearing gloves and gowns during high-contact resident care activities. The resident involved was a male with multiple medical conditions, including hemiplegia, seizures, an intracranial abscess, neuromuscular dysfunction of the bladder, malnutrition, and a gastrostomy. His clinical records indicated severe cognitive impairment and dependency on staff for all activities of daily living. Despite these conditions, there were no specific orders or care plans for Enhanced Barrier Precautions for this resident, which contributed to the oversight by the CNAs. Interviews with the CNAs and facility staff revealed a lack of understanding and implementation of Enhanced Barrier Precautions. The CNAs were unaware of the necessity for these precautions, and the Director of Nursing (DON) expressed skepticism about their benefits. The Assistant Director of Nursing (ADON) acknowledged providing verbal training on infection control but lacked documentation to confirm it. The facility's policy, aligned with CDC guidelines, recommended Enhanced Barrier Precautions for residents with indwelling medical devices, yet this was not consistently applied or understood by the staff.
Failure to Notify Family and Physician After Resident's Fall
Penalty
Summary
The facility failed to immediately inform a resident's representative and consult with the resident's physician following an accident that resulted in injury and required hospital transfer. The incident involved a male resident who had a history of cellulitis, repeated falls, muscle weakness, and reduced mobility. The resident experienced an unwitnessed fall in the facility's lobby, resulting in a displaced subcapital femoral neck fracture of the right hip. Despite the severity of the injury and the subsequent ambulance transfer to the hospital, the resident's emergency contact was not notified immediately. Interviews and record reviews revealed that the facility's staff did not follow the established protocol for notifying the resident's family and physician after a significant change in condition. The Licensed Vocational Nurse (LVN) responsible for contacting the family attempted to reach the emergency contact twice on the day of the fall but failed to document these attempts until five days later. The Director of Nursing (DON) confirmed the lack of timely documentation and notification. The facility's policy mandates prompt notification of the resident's representative and physician in such situations, which was not adhered to in this case.
Failure to Properly Store, Label, and Date Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed multiple instances of improperly stored, labeled, and dated food items in the walk-in pantry, refrigerator, and freezer. Specifically, the pantry contained an opened package of turkey gravy mix, boxes of oatmeal creme pies, cereal boxes, cereal bowls, and loaves of bread, all without labels or dates. The walk-in refrigerator had a partially used loaf of raisin bread, bags of hamburger buns, shredded purple cabbage, shredded carrots, bags of a yellow substance possibly liquid eggs, packages of ham, packages of chili, and boxes of margarine, all without labels or dates. The freezer contained large packages of meat in a tray with no labels or dates. Interviews with kitchen staff and the Dietary Manager (DM) confirmed that the lack of labeling and dating could result in food not being servable and potentially causing illness to residents. The facility's policy, dated October 2009, mandates that all refrigerated, ready-to-eat foods must be properly covered, labeled, and dated with a use-by date. The policy also states that leftovers must be dated and are only good for three days before they must be discarded. The failure to adhere to these guidelines was evident in the observations made during the survey.
Failure to Submit Direct Care Staffing Information to CMS
Penalty
Summary
The facility failed to electronically submit to CMS complete and accurate direct care staffing information for FY Quarter 1 2024 (October 1-December 31). This deficiency was identified based on interview and record review. The CMS PBJ report indicated that the facility did not submit the required staffing data for the specified quarter. During an interview, the Administrator (ADM) stated that IT Corp was responsible for uploading the PBJ data. In a subsequent phone interview, IT Corp admitted that the failure to upload the data was due to human error, as they oversee fifteen buildings and missed this particular facility. The facility's undated staffing policy mandates that direct care staffing information, including agency and contract staff, be submitted to the CMS payroll-based journal system at least once a quarter.
Failure to Provide Engaging Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of residents, as evidenced by observations, record reviews, and interviews. Specifically, the facility did not ensure that three of the seven residents interviewed received adequate notification of activities, nor did it provide activities that met the residents' needs or desires. The Activity Director (AD) was observed engaging in coloring activities with residents, which were not suitable for all participants, particularly one resident who had a contracture from a stroke and could not participate in coloring. Additionally, the activity calendar did not accurately reflect scheduled activities, and the font size was too small for residents to read, further hindering their participation. The bulletin board in the dining room, which could have been used to announce activities, was blank and not utilized. Interviews with residents and staff revealed that the activities provided were not engaging or beneficial, and the AD did not offer a variety of stimulating activities. The Director of Nursing (DON) acknowledged that the AD was responsible for ensuring engaging activities for residents and recognized the potential negative outcomes of not providing such activities. Despite the facility's policy allowing residents to participate in social, religious, and community group activities, the AD primarily offered coloring pages, which were not engaging for all residents. The lack of stimulating activities and inadequate communication about scheduled activities placed residents at risk of boredom and a decline in their quality of life. The facility's failure to provide an appropriate and engaging activity program was evident through multiple observations and interviews, highlighting a significant deficiency in meeting residents' needs and preferences.
Unqualified Activities Director
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. The Activities Director (AD) had been working at the facility for about six months without the necessary certification, as she was waiting for the facility to pay for the classes. The Administrator (ADM), Assistant Director of Nursing (ADON), and Director of Nursing (DON) were all aware of the AD's lack of certification. Interviews with staff indicated concerns that the lack of certification could result in activities that were not beneficial or stimulating for the residents. A review of the AD's personnel file confirmed the absence of any training or certification related to activities. Additionally, a policy regarding certified staff for activities was requested but not provided before the survey exit.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles. During observations, it was found that a medication cart for Hall 300 and part of Hall 200 contained a loose pill, and three insulin medications without open dates. Additionally, three insulin medications in Hall 100 and part of Hall 200 were past their expiration dates. LVN A left two bubble packs of medication unattended on top of the medication cart while administering medications to a resident, and LVN B did not lock her medication cart while going into a resident's room to administer medication. Interviews with LVN B, LVN A, the ADON, and the DON confirmed the potential negative outcomes of these actions, including the risk of drug diversion, drug overdose, and accidental or intentional administration to the wrong resident. The facility's policies on securing medication carts and administering medications were reviewed, revealing that the medication carts must be securely locked at all times when out of the nurse's view, and that expiration dates must be checked prior to administering medications. The facility's failure to adhere to these policies placed residents at risk for adverse reactions and complications.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not performing proper hand hygiene (HH) and glove changes. LVN B did not perform HH before or after donning and doffing gloves while performing blood sugar checks and administering insulin to a resident. Similarly, LVN A did not perform HH before preparing medication for a resident with a gastrotomy tube and failed to clean the bedside table before setting up the medication. Additionally, LVN A did not perform HH during incontinent care or wound care for a resident with a Stage 3 wound to the coccyx. CNA D also failed to perform HH or change gloves after cleaning a resident during incontinent care. During an observation, CNA D cleaned the resident's bottom but did not perform HH or change gloves before touching the clean brief or draw sheet. In another instance, LVN A, while performing incontinent care and wound care for a resident, did not remove gloves or perform HH after cleaning stool from the resident before touching the resident's gown or other items. LVN A only performed HH after removing gloves and before starting wound care, but did not perform HH or change gloves between the dirty and clean portions of the wound care procedure. Interviews with staff, including CNA D, LVN A, the ADON, and the DON, confirmed the lack of proper HH and glove changes during these procedures. The facility's policies on perineal care, wound care, and hand hygiene were reviewed and found to be in place, but not followed by the staff. No policy for medication administration via gastrotomy tube was provided by the facility.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails, and obtain informed consent prior to installation of bed rails with residents or their resident representatives. Specifically, Resident #12 had two one-quarter bed rails installed on both sides of his bed without any documentation of physician orders, consent, or a safety assessment prior to installation. This oversight was identified through observation, interview, and record review, revealing that the facility did not follow its own policy regarding the proper use of side rails, which mandates an assessment, consent, and documentation in the resident's care plan. Resident #12, a male with diagnoses including muscle weakness, vascular dementia, muscle wasting and atrophy, and neuroleptic-induced parkinsonism, was found to have bed rails installed without the necessary procedural steps being followed. The resident's care plan and clinical records lacked any mention of bed rail use, physician orders, or a bed rail safety assessment. Interviews with the ADON, CNA, and DON confirmed that the facility's policy was not adhered to, and they acknowledged the potential risks associated with improper bed rail use. The facility's policy on the proper use of side rails, dated December 2016, was not followed, leading to this deficiency.
Deficiencies in Nursing Competencies and Infection Control
Penalty
Summary
The facility failed to ensure that LVN A used proper techniques when providing wound care, incontinent care, and administering medications via gastrostomy tube. During an observation, LVN A was seen administering medication via a PEG tube to a resident and encountered difficulties because the resident had received a bolus feeding before medication administration. LVN A admitted to not having received training for administering medications via PEG tube at the facility. The DON confirmed that there were no competency checkoffs for gastrostomy tube care and medication administration for LVN A. Further observations revealed that LVN A and CNA E did not follow proper hand hygiene (HH) and glove-changing protocols during incontinent care and wound care for a resident. LVN A failed to change gloves and perform HH after cleaning the resident's stool and before touching the resident's gown and other items. Additionally, LVN A did not change gloves or perform HH between the dirty and clean portions of wound care. Both LVN A and the ADON acknowledged that these lapses could increase the risk of infection for residents. Record reviews showed that LVN A had an annual training but no return demonstration of competency was performed. The facility's policies on medication administration, perineal care, wound care, and hand hygiene were not followed. The BOM confirmed that the facility did not have competency checkoffs for staff, which contributed to the deficiencies observed in the care provided by LVN A.
Significant Medication Error Involving Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically involving the administration of insulin. During an observation of medication administration, an LVN administered insulin to a resident using an insulin pen that belonged to another resident. The LVN confirmed the open date on the insulin pen and administered 10 units of Novolog to the resident. After returning to the medication cart, the LVN realized the insulin pen belonged to another resident. Although there was no adverse reaction since the medication and dosage were correct, the error was significant as it involved the use of another resident's medication. The resident involved was a male with multiple diagnoses, including Type 1 diabetes mellitus, chronic obstructive pulmonary disease, end-stage renal disease, and other chronic conditions. The resident had a moderate cognitive impairment and required assistance with various activities of daily living. The resident's care plan indicated that he was insulin-dependent, and his physician's orders specified a sliding scale for insulin administration. Interviews with the ADON and DON highlighted the potential negative outcomes of such medication errors, including the risk of resident injury and complications. The facility's policies on medication administration and adverse consequences were reviewed, revealing that new personnel should be accompanied by a charge nurse for a minimum of three days to ensure proper procedures are followed. The LVN involved in the incident was on her first day back at the facility after a while, and the error occurred despite the facility's established procedures for medication administration and resident identification.
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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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