Legacy At Jacksonville
Inspection history, citations, penalties and survey trends for this long-term care facility in Jacksonville, Texas.
- Location
- 810 Bellaire St., Jacksonville, Texas 75766
- CMS Provider Number
- 676092
- Inspections on file
- 29
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Legacy At Jacksonville during CMS and state inspections, most recent first.
Improper eye drop administration and controlled substance count documentation were observed. An LVN administered artificial tears to a resident without using the full eye drop technique described in the facility policy, including gloves, pulling down the lower eyelid, and instructing the resident to look up. In addition, an RN and LVNs on multiple med carts either signed narcotic count sheets at the start of the shift or failed to sign them at shift change, despite stating they knew the count should be verified and documented after completion.
Failure to complete a baseline care plan within 48 hours of admission for a resident with pneumonia, CHF, CKD, COPD, prostate cancer, osteoarthritis, and weakness. The resident had a BIMS score of 00, required extensive ADL assistance, and had multiple allergies listed in physician orders, but no baseline care plan was found in the record. The DON stated the 48-hour care plan should have been completed on admission and that it was not done because the Nursing admission assessment was incomplete.
An LVN received a delivery of hydrocodone-acetaminophen tablets for a resident with dementia and diabetes, then placed the controlled medication card on the nurse’s station desk instead of securing it under double lock as required. The LVN charted for about two hours with the narcotics at her workstation, left to assist another resident without locking them up, and returned to find the medication card missing. Other LVNs confirmed seeing the delivery but did not see the drugs locked away or left in the open, and no residents were noted near the nurse’s station during the period. The resident had an active PRN order for hydrocodone-acetaminophen, had received a dose earlier that day with remaining tablets documented on the narcotic log, and later appeared calm and pain-free, reporting that pain medication was available and effective.
A resident with a feeding tube did not have enhanced barrier precautions (EBP) included in her care plan, despite requiring them. The care plan acknowledged the feeding tube but omitted EBP, and there was no physician order for EBP. Staff interviews confirmed the care plan was incomplete and did not reflect all necessary interventions, contrary to facility policy.
A resident with a feeding tube did not receive care in accordance with enhanced barrier precautions, as both a CNA and an LVN provided incontinent care without donning required PPE. There was no EBP signage or PPE available outside the room, and the resident's care plan and orders did not address EBP. Staff interviews confirmed awareness of EBP requirements, but the lapse occurred after the resident changed rooms and necessary precautions were not maintained.
The facility failed to inform residents about how to file grievances, as revealed by interviews and record reviews. Residents were unaware of the grievance process, and grievance forms were not readily available at designated locations. The Social Worker and Administrator had not adequately communicated or facilitated the grievance process, leading to a deficiency in resident rights awareness.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in their care plans. One resident's assessment was incorrectly coded for restraint use, despite no evidence of restraints. Another resident's assessment inaccurately reflected their PASRR status, due to a misunderstanding of the requirements. These errors were acknowledged by the facility's staff, highlighting a need for accurate documentation.
A facility failed to maintain an effective infection control program when an LVN did not don a gown before administering medication through a PICC line for a resident with multiple diagnoses. The LVN did not recognize the need for Enhanced Barrier Precautions, and there was no signage or PPE container outside the resident's room. The DON confirmed the expectation for staff to follow EBP guidelines to reduce infection risks.
Improper Eye Drop Administration and Controlled Substance Count Documentation
Penalty
Summary
Pharmaceutical services were not provided in a manner that ensured accurate acquiring, receiving, dispensing, and administering of medications for one resident and for five medication carts reviewed. During a medication pass observation, an LVN administered artificial tears to a 74-year-old female resident with diagnoses including COPD, dysphagia, hypothyroidism, hypertension, chronic viral hepatitis C, contracture of the left hand, cognitive communication deficit, failure to thrive, and myalgia. The resident’s physician order directed artificial tears ophthalmic solution to be instilled in both eyes three times daily for dry eyes. During the observation, the LVN assembled the equipment and used general aseptic technique, but did not use the proper technique for eye drop administration. The LVN did not don gloves, did not gently pull down the lower eyelid to create a conjunctival pocket, and did not instruct the resident to look upward during instillation. The LVN stated she had been trained in the proper administration and care of eye drops and described the correct technique during interview. The DON stated nursing staff were trained in the proper administration of eye drops and acknowledged that the observed steps of the procedure were not followed. The facility also failed to ensure proper controlled substance count documentation on multiple medication carts. On one cart, an RN signed both the oncoming and off-going shift count sheets at the beginning of the shift; on another cart, an LVN did the same. On two other carts, one LVN and another LVN did not sign the controlled substance count sheets at the beginning of their shifts. Interviews with the nurses reflected awareness that the narcotic count sheet should be signed only after the count is completed and verified at shift change. The DON stated nurses should only sign after verifying the medications on hand matched the controlled drug count record and said she was not aware staff were not signing at the correct times.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #92. The resident was an [AGE] year-old male admitted with diagnoses including pneumonia, chronic congestive heart failure, chronic kidney disease, COPD, malignant neoplasm of the prostate, osteoarthritis, and weakness. His physician orders listed allergies to aluminum hydroxide, calcium carbonate, cefdinir, magnesium carbonate, magnesium hydroxide, and Protonix. An admission MDS showed a BIMS score of 00, indicating difficulty with short-term memory, orientation, and attention, and that he required extensive assistance with most activities of daily living. The medical record showed that Resident #92 did not have a baseline care plan. The resident was discharged from the facility on 02/14/2026. During interview, the DON stated that a 48-hour care plan should have been completed when the charge nurse admitted the resident, and that the Nursing admission Assessment was intended to identify concerns and trigger the baseline care plan. The DON said the baseline care plan was not completed because the Nursing admission Assessment was incomplete, and she was new to the facility and unsure who was responsible for ensuring baseline care plans were completed. The facility policy stated that the baseline care plan was to be developed within 48 hours of admission and include minimum healthcare information such as initial goals based on admission orders, physician orders, dietary orders, therapy services, and PASARR recommendations if applicable.
Unsecured Hydrocodone Tablets Left at Nurse’s Station and Subsequently Missing
Penalty
Summary
The deficiency involves the facility’s failure to securely store controlled medications in accordance with professional standards and facility policy. On the 400 hall, an LVN received a delivery of hydrocodone-acetaminophen 5-325 mg tablets for a male resident with Type 2 diabetes, senile degeneration of the brain, and unspecified dementia. The resident had an order for one tablet by mouth every 8 hours as needed for pain, with a 30‑day supply (90 tablets) last filled on 1/15/2026 and a next fill date of 2/10/2026. On 2/10/2026 at approximately 3:00 p.m., after another nurse co-signed for receipt of the controlled medication, the LVN placed the hydrocodone medication card containing 45 tablets on the desk at the nurse’s station instead of immediately locking it in the medication cart as required. The LVN then began charting and kept the hydrocodone tablets at the nurse’s station for approximately two hours. During this time, she became distracted, left the nurse’s station to respond to a resident’s needs, and forgot to secure the narcotics. When she returned, the medication card was missing. The LVN later documented that she had set the card down beside her while charting and that she was unable to locate the medication after searching medication carts, medication rooms, supply closets, and the treatment cart. Other LVNs working that day reported seeing the LVN take delivery of the medication but did not see whether it was locked up, and they did not observe the medication lying out in the open or residents near the nurse’s station counter during the relevant timeframe. Record review showed that the resident had received a dose of hydrocodone-acetaminophen earlier that morning at 7:30 a.m., with 30 tablets remaining on the narcotic administration log, and that the resident had an as‑needed order for moderate to severe pain. Subsequent observation of the resident found him seated in a wheelchair in a common area watching television, appearing calm and in no acute distress, with no facial grimacing or observable signs of physical distress. The resident reported that he took pain medication as needed, that it was always available when requested, and that it effectively controlled his pain. The facility’s written policy for controlled medications stated that Schedule II medications are to be stored under double lock in a locked cabinet or safe, separate from all other medications, which was not followed in this incident.
Failure to Develop Comprehensive Care Plan for Resident with Feeding Tube
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's medical, nursing, mental, and psychosocial needs. Specifically, a resident who was admitted with a feeding tube did not have enhanced barrier precautions (EBP) included in her care plan, despite requiring them. Record review showed that the care plan acknowledged the feeding tube but omitted EBP, and there was no physician order for EBP in the resident's consolidated orders. The resident was cognitively intact, dependent on staff for all activities of daily living, incontinent of bowel and bladder, and required a feeding tube. Interviews with facility staff, including the MDS nurse, DON, and regional reimbursement nurse, confirmed that the care plan was incomplete and did not reflect all necessary interventions for the resident. Staff acknowledged that the comprehensive care plan should have included EBP and that its omission could result in a lapse of care. The facility's policy requires that care plans be person-centered and address all identified needs, but this was not followed in this instance.
Failure to Implement Enhanced Barrier Precautions for Resident with Feeding Tube
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident who required enhanced barrier precautions (EBP) due to the presence of a feeding tube. Observations revealed that a CNA and an LVN provided incontinent care and repositioning to the resident without donning the required personal protective equipment (PPE), such as gowns and gloves. There was no signage on the resident's door indicating the need for EBP, nor was PPE available outside the room. The resident's care plan did not address EBP, and there was no physician order for EBP in the resident's records. Interviews with staff confirmed that both the CNA and LVN were aware that residents with feeding tubes should be on EBP and that proper PPE should be used during care. The LVN stated she was unsure why the necessary signage and PPE were not present and admitted to forgetting to use PPE. The DON, who also served as the infection prevention nurse, acknowledged responsibility for ensuring EBP measures were in place and attributed the lapse to the resident's recent room change, during which EBP signage and supplies were not transferred. The facility's policy required EBP for residents with indwelling medical devices, such as feeding tubes, but this protocol was not followed in this instance.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to ensure that residents were informed of how to file a grievance, affecting all eight residents interviewed confidentially. During a review of resident council meeting minutes from October 2024 to January 2025, it was found that the grievance form and its usage had not been explained to the residents. Interviews with the residents revealed that they were unaware of how to file a grievance, as neither the Activity Director nor the Social Worker had reviewed or explained the grievance process to them. The Social Worker stated that she explains the grievance form to residents when they have an issue but admitted she had never explained it to the resident council. She also mentioned that grievance forms were supposed to be available at the nurse's stations and the Administrator's office, but none were found during the surveyor's visit. The Administrator claimed to have reviewed the grievance form with residents in October 2024, but her signature was not on the meeting's signature log. Additionally, it took the Administrator over five minutes to produce a blank grievance form when requested.
Inaccurate MDS Assessments for Restraint Use and PASRR
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. Resident #17's quarterly MDS assessment was inaccurately coded for restraint use, despite no evidence of restraints being used. Observations and interviews with the resident and staff confirmed that no restraints were in place, and the MDS Nurse admitted the error was a typo. The Director of Nursing (DON) also confirmed the facility was restraint-free and acknowledged the incorrect coding. Resident #54's admission MDS assessment was inaccurately coded regarding the Preadmission Screening and Resident Review (PASRR). The resident had a history of mental illness, as indicated by previous PASRR evaluations, but the MDS assessment incorrectly marked the resident as not having a serious mental illness. The MDS Coordinator misunderstood the PASRR requirements, believing that since the resident did not qualify for specialized services, they should be marked as not having a mental illness. The DON also expressed confusion about the PASRR process, indicating a misunderstanding of the requirements. These inaccuracies in the MDS assessments could potentially place residents at risk for not receiving appropriate care and services. The errors were attributed to misunderstandings and misinterpretations of the RAI Version 3.0 Manual guidelines, which the facility used for completing MDS assessments. The facility's staff, including the MDS Nurse and DON, acknowledged the errors and the need for accurate documentation.
Infection Control Deficiency Due to PPE Non-Compliance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN B, who did not don a gown before administering medication through a PICC line for a resident. This oversight occurred during a medication pass observation, where LVN B verified the medication order, prepared the intravenous piggyback setup, and administered the antibiotic without wearing the required PPE gown. LVN B later acknowledged the importance of donning the appropriate PPE to reduce infection risk but did not consider the PICC line as a central line requiring such precautions. Additionally, there was no signage or PPE container outside the resident's room to indicate the need for Enhanced Barrier Precautions (EBP). The resident involved was an elderly female with multiple diagnoses, including encephalopathy, sepsis, pneumonia, acute cystitis, hemiplegia, and Type II Diabetes Mellitus. The facility's policy on Enhanced Barrier Precautions, which mandates the use of gowns and gloves during high-contact activities with residents having indwelling medical devices, was not followed. The Director of Nursing, who also serves as the Infection Preventionist, stated that the facility's policy requires staff to adhere to EBP guidelines to minimize infection transmission risks. Despite in-service training on infection control and EBP, the staff failed to implement these precautions effectively.
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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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