Lindan Park Care Center Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Richardson, Texas.
- Location
- 1510 N Plano Rd, Richardson, Texas 75081
- CMS Provider Number
- 675870
- Inspections on file
- 38
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lindan Park Care Center Lp during CMS and state inspections, most recent first.
A resident with severe cognitive impairments and dysphagia was force-fed by a CNA, leading to a deficiency in abuse prevention. The CNA pushed the resident's head back and rapidly fed her, causing distress. Despite the resident's care plan requiring specific feeding techniques, the CNA's actions were observed by a surveyor, who intervened. Interviews revealed differing views on the feeding method, but the facility's policy emphasized resident protection, which was compromised.
The facility failed to inform residents on how to file grievances anonymously, affecting their ability to voice concerns without fear of reprisal. Observations and interviews revealed that residents and staff were unaware of the grievance process, and grievance forms were not easily accessible. The facility's policy states residents have the right to file grievances without fear, but this was not effectively communicated.
The facility failed to adhere to food service safety standards, with deficiencies in labeling, dating, and sealing food items in the kitchen. Unsealed and expired items were found in both dry storage and refrigerator areas, including a dented can and improperly stored perishables. Staff interviews revealed a lack of awareness and oversight, despite existing policies requiring proper food storage and rotation practices.
A facility failed to conduct an accurate PASARR screening for a resident with serious mental disorders, leading to a risk of not receiving necessary services. The MDS Nurse did not verify the PL-1 form's accuracy, and the DON was unaware of a process to double-check these forms, despite the facility's policy requiring preadmission screening.
The facility failed to complete discharge summaries and medication reconciliations for two residents, impacting their continuity of care post-discharge. One resident was discharged home, and another to a hospital, both without necessary documentation. The absence of a Social Worker and inconsistent assignment of responsibilities contributed to these deficiencies.
The facility failed to display required notifications for residents and their representatives on how to file a complaint, as observed during a survey. The absence of the Adult Protective Services posting was confirmed by the Administrator, who acknowledged responsibility for ensuring such postings are displayed. A sign was later created and posted after the issue was identified.
A resident with COPD and other health issues experienced a significant drop in oxygen levels, but the facility failed to notify the physician as required by policy. RN A discovered the drop and administered a breathing treatment, but did not inform the physician, which could delay medical intervention.
A resident with severe cognitive impairment and multiple health conditions was found with unexplained bruising on the inner thighs during ADL care. The LPN documented the injury and informed the ADON, but failed to notify the physician or responsible party as required by facility policy. The physician and responsible parties only learned of the injury after the resident was hospitalized for unrelated reasons.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained bruising on the inner thighs. The injury was discovered by an LVN and observed by the ADON, but required notifications to the administrator, DON, physician, responsible party, and state agency were not made within the required timeframe. The incident was reported to the state agency two days late, contrary to facility policy and regulatory requirements.
A resident's care plan inaccurately included a diagnosis of Parkinsonism, despite the absence of such a diagnosis in their medical records. Facility staff, including the DON and MDS Nurse, confirmed the error but could not determine its origin. This discrepancy highlights a failure to maintain accurate clinical records, as required by the facility's documentation policy.
Resident Force-Fed by CNA, Resulting in Abuse Deficiency
Penalty
Summary
The facility failed to protect a resident from physical abuse when a Certified Nursing Assistant (CNA) force-fed the resident, causing psychosocial harm. The incident occurred when the CNA forcefully pushed the resident's head back and rapidly fed her large spoonfuls of food, despite the resident's attempts to stop drinking and subsequent coughing and sputtering. The resident, who was non-verbal and had severe cognitive impairments, was dependent on staff for eating due to her medical conditions, including dysphagia and dementia. The resident's care plan indicated that she required total assistance for eating and had specific dietary needs, including a pureed diet and thickened liquids. The care plan also noted that the resident's head should be elevated during meals to prevent swallowing difficulties. Despite these instructions, the CNA's actions were observed by a surveyor, who intervened and reported the incident to the Director of Nursing (DON). Interviews with the DON, the Administrator, and the resident's family member revealed differing perspectives on the feeding technique used by the CNA. The family member acknowledged that the technique was aggressive but believed it was necessary to meet the resident's needs. However, the Rehabilitation Director and other staff members confirmed that no aggressive techniques were required for feeding the resident. The facility's policy on abuse, neglect, and exploitation emphasized the protection of residents' health, welfare, and rights, which were compromised in this incident.
Failure to Inform Residents of Anonymous Grievance Filing Process
Penalty
Summary
The facility failed to adequately inform residents or their representatives on how to file grievances anonymously, affecting their ability to voice concerns without fear of discrimination or reprisal. This deficiency was identified through observations, interviews, and record reviews, which revealed that residents were not notified individually or through prominent postings about the grievance process. Specifically, three residents reviewed for knowledge of filing grievances were unaware of how to do so anonymously. Additionally, the grievance forms were not easily accessible, as observed when a surveyor struggled to open the frame containing the forms, and the forms fell out when the frame was finally opened. Interviews with residents during a confidential Resident Council meeting confirmed their lack of awareness regarding the location of grievance forms and the process for filing grievances anonymously. The Activities Director also demonstrated a lack of knowledge about the grievance forms' location and accessibility, further highlighting the facility's failure to ensure staff and residents were informed about the grievance process. The facility's Administrator indicated that grievances were typically filed verbally, suggesting a lack of emphasis on written or anonymous grievance procedures. The facility's policy on grievances, dated March 2017, states that residents have the right to file grievances without fear of reprisal, but the facility did not effectively communicate this right to its residents.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The deficiencies included improper labeling and dating of food items in both the dry storage and refrigerator areas. Specifically, several items were found unsealed, such as bags of noodles, sugar, and turkey gravy mix, as well as a metal pan of red Jello and a white plate with a burger setup. Additionally, expired items were not removed, including a package of seasoning mix and a bag of Parmesan cheese. A dented can of diced pears was also found on the shelf, which should have been removed to prevent potential contamination. Interviews with the Dietary Manager and staff revealed a lack of awareness and oversight regarding the expired and unsealed items. The Dietary Manager acknowledged the oversight and stated that all staff were responsible for ensuring items were not expired or unsealed. However, the staff interviews indicated a gap in the implementation of these responsibilities, as they were unaware of the existing issues. The staff were expected to follow the First In, First Out (FIFO) method for stock rotation, but the presence of expired and improperly stored items suggested a failure in this practice. The facility's policy and procedure manual for food storage outlined the requirements for proper food storage, labeling, and rotation, which were not followed. The manual emphasized the importance of using plastic containers with tight-fitting covers or sealable bags for storing opened packages and ensuring all items were labeled and dated. The failure to comply with these procedures posed a risk of cross-contamination and foodborne illnesses, as noted in the report.
Failure to Conduct Accurate PASARR Screening
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR review, which is necessary for residents with serious mental disorders or intellectual disabilities. This deficiency was identified for a resident who was admitted with diagnoses including depression, schizophrenia, and post-traumatic stress disorder. Despite these conditions, the resident's PASARR Level I screening incorrectly indicated no history of mental illness. The resident's quarterly MDS assessment showed severe cognitive impairment, and care plans noted deficits related to dementia, PTSD, and schizophrenia. Interviews with facility staff revealed that the MDS Nurse, responsible for entering PASARR information, did not verify the accuracy of the PL-1 form received from another facility. The Director of Nursing was unaware of any process to double-check the PL-1 forms, which placed the resident at risk of not receiving necessary PASARR services. The facility's policy requires preadmission screening to ensure appropriate placement and identify the need for specialized services, but this was not adhered to in this case.
Failure to Complete Discharge Summaries and Medication Reconciliation
Penalty
Summary
The facility failed to complete discharge summaries and medication reconciliations for two residents, which are essential components of discharge planning. Resident #58, a female with a history of dementia, hypertension, and other chronic conditions, was discharged home without a discharge summary or medication reconciliation. The facility's records indicated that her care plan and interventions related to discharge were canceled, and there was no documentation of a discharge summary or medication reconciliation in her clinical records. Similarly, Resident #59, a male with severe cognitive impairment and multiple health issues, was discharged to a hospital without a discharge summary or medication reconciliation. His care plan also showed canceled discharge planning interventions, and there was no evidence of a discharge summary or medication reconciliation in his records. Interviews with facility staff, including the MDS Nurse and the DON, revealed that the facility had been without a Social Worker for about two months, and the responsibility for completing discharge summaries had been inconsistently assigned to charge nurses. The facility's policy requires a discharge summary and post-discharge plan to be developed for residents anticipating discharge, which includes a comprehensive recapitulation of the resident's stay and a final summary of their status. However, due to the absence of a Social Worker and lack of oversight, these critical components were not completed for the two residents, potentially impacting their continuity of care post-discharge. Interviews with the Administrator and previous Social Worker highlighted the facility's challenges in maintaining consistent discharge planning processes, leading to the deficiencies identified in the report.
Missing Required Postings for Complaint Filing
Penalty
Summary
The facility failed to post the required notifications for residents or their representatives on how to contact someone to file a complaint. During observations conducted on March 5, 2025, between 10:00 AM and 3:00 PM, it was noted that the required Adult Protective Services posting was missing throughout the facility. An interview with the Administrator at 3:50 PM on the same day confirmed the absence of the posting. The Administrator acknowledged her responsibility for ensuring that the required postings are displayed. The Facility Surveyor/Liaison provided the Administrator with a link to order the necessary posting, and the Administrator subsequently created a sign and posted it on the wall.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition, which is a requirement under their policy. On January 26, 2025, RN A discovered that the resident's oxygen levels had dropped to 77% at 5:16 AM. Despite this significant change, the physician was not notified. RN A repositioned the resident and administered a breathing treatment, which increased the oxygen levels to 83-85%. However, the facility's policy mandates that the physician be informed of such changes, which did not occur in this instance. The resident in question was a male with multiple health issues, including chronic obstructive pulmonary disease (COPD), heart disease, and diabetes, among others. His care plan indicated moderate cognitive impairment and a need for assistance with activities of daily living. The resident was oxygen-dependent due to COPD, and his usual oxygen level while sleeping was around 85%. Despite the drop in oxygen levels, RN A did not perceive any immediate respiratory distress, as the resident's breathing appeared normal. Interviews with RN A and the physician revealed that the facility's policy was not followed. The physician stated that he was not informed of the resident's oxygen level drop to 77%, which he considered significant enough to warrant notification. The facility's policy requires notifying the physician of significant changes in a resident's condition, which includes a major decline that would not resolve without intervention. This oversight could potentially delay necessary medical intervention and affect the resident's health.
Failure to Notify Physician and Responsible Party of Injury of Unknown Origin
Penalty
Summary
The facility failed to notify a resident's physician and responsible party in accordance with policy when an injury of unknown origin was discovered. During ADL care, a nurse identified a large area of purplish-blue discoloration on the resident's bilateral inner thigh, but the resident, who had severe cognitive impairment and multiple comorbidities including dementia, diabetes, and poor impulse control, could not explain the cause. The nurse documented the finding and informed the Assistant Director of Nursing (ADON), but did not notify the physician, responsible party, administrator, or Director of Nursing as required. Interviews revealed that the ADON was aware of the injury but assumed the nurse would complete all necessary notifications and documentation. The administrator was not informed of the injury until several days later, after returning from a holiday absence. The physician and responsible parties were only made aware of the injury after the resident was admitted to the hospital for unrelated treatment. Both responsible parties learned of the injury from sources outside the facility, and the physician was not notified until the resident was transferred to the hospital. The facility's policy required immediate reporting and notification of injuries of unknown origin to the appropriate parties, including the physician and responsible party. However, this process was not followed, resulting in a delay in communication and potential delay in medical intervention for the resident. The deficiency was identified through record review, staff and responsible party interviews, and review of facility policy.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident with multiple complex medical conditions, including dementia, diabetes, schizophrenia, and severe cognitive impairment. The resident, who required assistance with activities of daily living, was found to have a large area of purplish-blue discoloration on both inner thighs during ADL care. The resident was unable to explain the cause of the discoloration, and there was no open area noted. The injury was discovered and documented by an LVN, who informed the Assistant Director of Nursing (ADON) at the time. Despite the discovery of the injury, the required notifications to the administrator, DON, physician, responsible party, and the state agency were not made within the mandated 24-hour timeframe. The ADON, who was present when the injury was discovered, relied on the LVN to document and report the incident, but did not follow up to ensure that the notifications were completed. As a result, the administrator and DON were not informed of the injury until two days later, after the holiday period had ended, and the report to the Texas Health and Human Services was submitted late. A review of the facility's abuse and neglect reporting policy confirmed that staff are required to immediately report injuries of unknown origin to the appropriate parties and state agencies, in compliance with federal and state regulations. The failure to follow this policy resulted in a delay in reporting the incident, as the responsible staff member did not complete the necessary notifications and documentation as required.
Inaccurate Diagnosis in Resident Care Plan
Penalty
Summary
The facility failed to maintain accurate clinical records for a resident, as evidenced by an incorrect diagnosis of Parkinsonism included in the resident's care plan. The resident, a male with multiple diagnoses including Multiple Sclerosis, Major Depressive Disorder, and Bipolar Disorder, did not have Parkinsonism listed in his medical records or MDS assessments. Despite this, the care plan was updated to reflect limited physical mobility related to Parkinsonism, which was not a diagnosis the resident had. Interviews with facility staff, including the DON, Director of Therapy, MDS Nurse, and the resident's Nurse Practitioner, confirmed that the resident did not have a diagnosis of Parkinsonism. The MDS Nurse and other staff were unable to determine how the incorrect diagnosis was added to the care plan. The facility's policy on charting and documentation emphasizes the need for complete and accurate records, which was not adhered to in this case, potentially leading to incorrect care for the resident.
Latest citations in Texas
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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