Los Arcos Del Norte Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 11169 Sean Haggerty, El Paso, Texas 79934
- CMS Provider Number
- 676283
- Inspections on file
- 38
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Los Arcos Del Norte Care Center during CMS and state inspections, most recent first.
The facility did not promote or facilitate resident self-determination by failing to support resident choice, resulting in a deficiency related to resident autonomy.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
The facility did not adequately protect resident-identifiable information or failed to maintain medical records according to professional standards, as identified by surveyors.
Several residents with complex needs, including chronic hygiene refusal, wandering into other residents' rooms, and sexually inappropriate behaviors, did not have these issues addressed in their care plans. Despite staff awareness and documentation of these behaviors, the care plans lacked measurable objectives, time frames, and specific interventions, leaving staff without clear guidance to address the residents' needs.
The facility did not document two separate incidents involving two residents—one alleging verbal mistreatment by a staff member and another reporting theft of money—in their medical records, despite both events being reported to the state and investigated. Facility leadership confirmed that nursing staff were responsible for documenting these incidents, in accordance with facility policy and professional standards.
A resident with a chronic skin condition and moderate cognitive impairment alleged mistreatment during a shower, but staff failed to perform or document a timely skin assessment as required by facility policy. Interviews confirmed that the assessment was either delayed or not documented, and the incident was not properly recorded in the medical record, resulting in a failure to follow abuse prevention procedures.
Two residents experienced deficiencies in their living environment: one was moved to a new room without notification or consent, resulting in damage to her personal property, while another, with severe cognitive impairment, resided in a room lacking any personal items or homelike features. Staff interviews and record reviews confirmed that facility policies regarding resident notification, involvement, and room personalization were not followed.
Surveyors found that several medication and treatment carts contained bottles of Betadine Iodine, Chlorhexidine Gluconate, and Pro-stat liquid medication with dried drippings on their sides. Staff, including LVNs and the DON, acknowledged that bottles should be cleaned after each use, but some medications were noted as difficult to keep clean. The facility's policy lacked specific instructions on maintaining bottle cleanliness.
During a meal service, surveyors observed that food trays were transported and stored on mobile racks covered with plastic bags instead of insulated carts, resulting in several hot food items being served below the required temperature. The DON and Dietary Manager confirmed the use of plastic bags to keep food warm and acknowledged resident complaints about cold food. Test tray sampling showed that some food items did not meet the facility's policy for safe food temperatures.
Surveyors found that kitchen staff did not consistently use beard restraints or hairnets, and failed to properly seal, label, and date opened food items in both storage and preparation areas. The deep fryer was left uncovered and unclean, and multiple food containers were not stored according to professional standards, despite staff training on these procedures.
A facility with 124 beds failed to employ a qualified full-time social worker, as the only social worker present continued to provide services with an expired license. Leadership and HR were aware of the expired status, and no other full-time social worker was available to provide oversight or coverage, resulting in noncompliance with licensure requirements.
The facility did not ensure that direct care staff, including an Interim Administrator, DON, Med Aide, ADON, and LVNs, completed mandatory training on effective communication, as training records were missing or incomplete and could not be provided during the survey.
A review found that several staff members, including administrative and clinical personnel, lacked documentation of required training on resident rights and facility responsibilities. Interviews revealed that new staff and leadership were unaware of where training records were kept, and efforts to locate or compile these records were unsuccessful. The facility was unable to provide evidence of completed training for multiple employees.
The facility did not provide or document required annual or new hire training on abuse, neglect, exploitation, and dementia care for several staff members, including the Interim Administrator, DON, ADON, Med Aide, RN, LVN, and Social Worker. Multiple staff were unable to locate or produce training records when requested by surveyors, and policies regarding required staff training were not provided.
The facility did not provide or document required training on its QAPI program for multiple staff members, including administrative, nursing, social work, maintenance, and dietary personnel. Training records were missing or could not be located, and staff responsible for maintaining these records were unaware of their location or existence. This resulted in a deficiency due to staff being uninformed about the facility's quality assurance and performance improvement efforts.
The facility did not provide or document required infection prevention and control training for multiple staff members, including administrative, nursing, maintenance, social work, and dietary personnel. Key staff and corporate representatives were unable to locate or produce training records or related policies when requested by surveyors.
The facility did not ensure that required staff, including administrative, nursing, and support personnel, received and had documentation of compliance and ethics training. Multiple staff members and temporary leadership were unable to locate or provide the necessary training records during the survey, resulting in a deficiency for lack of documented mandatory training.
The facility did not maintain or provide documentation of required behavioral health training for multiple staff members, including administrative, nursing, social work, maintenance, and dietary personnel. Despite efforts by new and temporary staff to locate the records, the facility was unable to demonstrate that the necessary training had been completed.
Two residents with severe cognitive impairment and a history of falls were found without access to their call lights, as the devices were observed on the floor and out of reach. Despite care plans and facility policy requiring call lights to be kept within reach, staff did not ensure this, as confirmed by interviews with a CNA, ADON, and DON.
A resident with multiple chronic conditions, including the need for peritoneal dialysis, did not have dialysis care addressed in her comprehensive care plan. Although dialysis was ordered and documented, staff interviews revealed it was omitted from the care plan due to MDS processes, with reliance on verbal communication and order sets instead. Facility leadership confirmed that dialysis should have been included in the care plan to ensure all staff were informed of the resident's needs.
Two residents who were unable to perform ADLs independently did not receive necessary nail care, resulting in long, untrimmed, and unclean fingernails. Despite care plans and facility policy requiring assistance with personal hygiene, staff did not consistently provide or document nail care, and one resident was not offered nail trimming since admission.
A resident who was fully dependent for ADLs and had significant dental and medical needs did not receive necessary assistance in obtaining routine dental care. Despite requests for dental services and a history of oral health issues, there was confusion among staff regarding responsibility for scheduling and monitoring dental appointments, and no clear documentation or follow-up to ensure the resident received routine dental services as required by facility policy.
A CNA failed to perform hand hygiene after removing soiled gloves and before donning new gloves while providing perineal care to a resident with severe cognitive impairment and incontinence. This lapse was observed during care and confirmed by interviews with the CNA, DON, and ADON, all of whom acknowledged that facility policy and standard procedures require hand hygiene at these steps.
The facility failed to maintain a clean and safe environment, with trash and biohazard materials found on floors across all hallways. Staff interviews revealed inconsistencies in responsibilities for trash disposal, contributing to the deficiency. The presence of trash and biohazard materials, such as bloody gauze, posed an infection risk, contrary to the facility's policy for a dignified environment.
A resident with dementia and a history of falls did not have a Bed Rail Assessment or orders for bed rail use, leading to a deficiency in care. The resident reported using the bed rails independently and experienced an incident where their wrist hit the rail, resulting in swelling and pain. Facility staff confirmed the absence of necessary assessments and orders, acknowledging the risk of entrapment. The facility's policy requires evaluations for bed rail use, which were not conducted in this case.
A facility failed to accurately reflect a resident's use of bed rails in the MDS assessment. The resident, diagnosed with dementia and a history of falls, was observed using bed rails, but this was not documented in the MDS. Interviews with staff revealed a lack of awareness about the necessity of coding bed rail use, potentially risking inadequate care.
A facility failed to implement a comprehensive care plan for a resident's use of bed rails, despite the resident's history of dementia and falls. The care plan did not include the use of bed rails, which was observed to pose a risk when the resident's wrist hit the rail. Interviews with staff revealed that the care plan should have included this information to ensure proper care and safety, as per the facility's policy.
A facility failed to ensure a safe environment by not engaging the brakes on a mechanical lift during a resident transfer, despite staff training on proper procedures. The resident, with severe cognitive impairment and mobility issues, required extensive assistance. The facility's policy emphasized safety checks, which were not followed, leading to a potential risk of injury.
A resident did not receive their prescribed Cilostazol medication due to unavailability, as noted in the MAR. The facility failed to document or report the issue to the physician, despite the resident's history of hypertension and strokes. Staff interviews revealed a lack of recollection and follow-up actions regarding the medication's unavailability.
The facility failed to document a resident's transfer request and included an error in another resident's care plan regarding eyeglasses. The DON and BOM did not record the transfer request, and an LVN admitted to mistakenly documenting eyeglass use. These lapses in documentation could lead to misleading information affecting resident care.
A facility licensed for 124 beds failed to employ a full-time social worker since early August, leading to management staff, including the DON, handling social worker duties. This resulted in grievances not being properly addressed and a resident's transfer request not being followed up, as confirmed by the Administrator. The position had been posted online, but remained unfilled, increasing workloads for existing staff.
The facility failed to notify the State LTC Ombudsman of a resident's discharge, as required. The Ombudsman had not received a discharge list for several months, and the new social worker was unaware of the responsibility. Interviews revealed confusion among staff about who should send the notices, despite the facility's policy stating it should be done at the same time as notifying the resident.
The facility failed to ensure that a high-risk resident's fall mat was positioned bedside while the resident was in bed. The resident, with a history of falls and multiple diagnoses, was found without the fall mat in place, contrary to the care plan and facility policy. Staff interviews confirmed the oversight and the requirement for the mat to be in place to prevent injuries.
The facility failed to post an oxygen sign outside a resident's room, who required oxygen therapy for acute respiratory failure with hypoxia. This oversight was confirmed by the RN and DON, who acknowledged the necessity of the sign to inform staff and visitors and prevent fire hazards.
A resident with multiple diagnoses and a high fall risk was inaccurately documented as low risk for falls by a nurse, despite previous assessments and the care plan indicating otherwise. The DON confirmed the error and acknowledged the potential impact on the resident's treatment.
The facility failed to conduct neurological checks for two residents after they experienced falls, despite facility policies requiring such checks for unwitnessed falls or suspected head injuries. This deficiency placed the residents at risk of undetected head injuries and other complications.
A facility failed to use a Hoyer lift for a resident requiring a two-person transfer, leading to an incident where the resident slipped and nearly fell. The CNA attempted the transfer alone, against the care plan and facility policy, placing the resident at risk of injury.
A facility failed to maintain an infection control program, as a resident's catheter drainage bag was observed lying on the floor multiple times. Despite policies and care plans instructing proper storage, staff interviews confirmed the lapse in protocol, posing a risk of infection.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. The report identifies a deficiency related to the lack of support for resident autonomy, specifically in the area of enabling residents to make their own choices regarding their care and daily life. No further details about specific actions, inactions, or events, nor information about individual residents or their medical history, are provided in the report.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that either resident information was not properly protected or medical records were not kept as required by professional guidelines. No additional details about specific residents, their medical history, or the exact nature of the records or information involved are provided in the report.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for several residents, as required by regulation. For one resident with a chronic skin condition and moderate cognitive impairment, there was a documented pattern of refusing showers, resulting in poor hygiene, strong body odor, and extremely dry skin. Despite repeated refusals and family reports of long-standing hygiene issues, the care plan did not address the resident's refusal of showers or outline interventions to address this behavior. Staff interviews confirmed awareness of the issue, but no care plan was in place to guide consistent care or document effective strategies. Another resident with Alzheimer's disease and depression exhibited wandering behaviors, specifically entering other residents' rooms and rummaging through their belongings, which led to altercations with other residents. Although the care plan addressed wandering in general, it did not specifically address the behavior of entering other residents' rooms. Staff and leadership interviews confirmed that this was a known, ongoing behavior, but it was not reflected in the care plan, leaving staff without clear guidance on how to manage or prevent these incidents. Two additional residents displayed sexually inappropriate behaviors, including exposing themselves and inappropriate physical contact with other residents. In both cases, these behaviors were not included in the residents' care plans, despite being documented in progress notes and incident reports. Staff interviews revealed that these were new or ongoing behaviors that had not been care planned, and the lack of documentation meant that staff were not fully informed or prepared to address these behaviors. The facility's own policy required that care plans include refusals, behaviors, and interventions, but this was not followed for these residents.
Failure to Document Resident Incidents in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, as required by accepted professional standards. For one resident, who had a history of depression and dementia but demonstrated little to no cognitive impairment, an incident occurred in which the resident alleged that a staff member called her 'evil' during an activity. Although the incident was reported to the state, investigated, and statements were collected from staff and other residents, there was no documentation of the incident in the resident's medical chart. Both the Director of Nursing (DON) and the Administrator confirmed that this incident should have been documented by nursing staff, as it pertained to the resident's care and behavior needs. In a separate case, another resident with moderate cognitive impairment and a diagnosis of metabolic encephalopathy versus TIA reported that $40 was stolen from his wallet while he was napping. The incident was reported to the state, the resident's room and wallet were searched with his permission, and the family and local police were notified. Despite these actions, there was no documentation of the incident in the resident's medical record. Interviews with the Assistant Director of Nursing (ADON), a Licensed Vocational Nurse (LVN), the DON, and the Administrator all confirmed that the incident was not documented as required. The facility's own documentation guidelines require that all individuals who document in the medical record follow good clinical record practice. The lack of documentation for these incidents was acknowledged by facility leadership, who stated that nurses are responsible for documenting such events to ensure continuity of care. The omission of these records could result in inaccurate resident records and impact the provision of needed services due to documentation errors.
Failure to Implement Abuse Prevention Policy and Timely Skin Assessment
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for one resident. Specifically, after an incident in which a resident alleged mistreatment during a shower, the facility did not perform or document a timely skin assessment as required by its abuse policy. The policy mandates that an immediate assessment and documentation in the medical record occur upon discovery of alleged abuse, but this was not completed following the resident's allegation. The resident involved had a history of chronic skin conditions and was moderately cognitively impaired. She had refused showers previously and required a two-person assist for bathing. On the day of the incident, two CNAs assisted with her shower, during which the resident became upset and alleged that she had been scrubbed too hard and that both hot and cold water were used. Staff interviews confirmed that no skin assessment was documented on the day of the incident, and the only available assessment was completed two days later without specifying its relation to the allegation. Interviews with nursing staff and administration revealed that the required documentation and assessment were not completed at the time of the incident. The DON and ADON acknowledged that the lack of immediate assessment and documentation was a failure to provide adequate care and ensure continuity. The facility's own policy was not followed, as the assessment and documentation were either delayed or omitted, placing residents at risk for abuse and neglect.
Failure to Ensure Resident Rights and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for two residents, resulting in deficiencies related to resident rights and environmental standards. One resident, a cognitively intact female with diagnoses including toxic liver disease and muscle wasting, was moved to a different room without her consent or prior notification. During this unannounced transfer, her personal portable closet was broken by facility staff and not replaced, despite her requests. The resident expressed that her rights were violated by not being included in the decision-making process regarding her room change and by having her belongings handled without her presence. Multiple staff interviews confirmed that the resident was not notified or involved in the transfer, and the facility's own grievance summary documented her formal complaint about the incident. Another resident, a male with severe cognitive impairment due to dementia and Alzheimer's disease, was found to be living in a room that lacked any personal items or homelike touches. Observations revealed that his room was empty except for snacks on the nightstand, with bare walls and no evidence of personalization. Interviews with staff indicated that they were unaware of the lack of personal items in his room, and the social worker acknowledged that the resident carried family photos in his pockets but had not facilitated displaying them in his room. The facility's policy required that resident rooms be arranged to preserve dignity and contribute to a positive self-image, but this was not followed in this case. Both deficiencies were substantiated through observations, interviews, and record reviews, including care plans and facility policies. The failures included not protecting a resident's personal property during a room transfer, not notifying or involving the resident in the process, and not ensuring that another resident's room was personalized to create a homelike environment. These actions and inactions were directly linked to the facility's failure to honor residents' rights to a safe, clean, comfortable, and homelike environment, as required by regulation and facility policy.
Medication Storage and Cleanliness Deficiency
Penalty
Summary
Surveyors observed that the facility failed to maintain proper storage and cleanliness of medication bottles in three out of four medication and treatment carts. Specifically, bottles of Betadine Iodine, Chlorhexidine Gluconate solution, and Pro-stat liquid medication were found with dried drippings running down their sides in the 100, 200, and 300 hall carts. These observations were made during multiple checks of the medication carts. Staff interviews confirmed that medication bottles should be cleaned after each use to prevent cross contamination, but it was acknowledged that some medications, such as iodine and pro-stat, are difficult to keep clean due to their properties. The Director of Nursing and regional nurse both stated that staff were trained to clean bottles after each use, but there was uncertainty about when the last training occurred. Review of the facility's Medication Management Program policy revealed no specific instructions regarding the requirement to keep bottles clean and free of dried drippings. The deficiency was identified through direct observation, staff interviews, and policy review, with no mention of specific residents affected or their medical conditions at the time.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature during a meal observation. Surveyors observed that meal trays were transported and stored on mobile Sheet Pan Racks covered with clear plastic trash bags, rather than insulated or heated carts. When questioned, the DON did not provide an explanation for how the food was kept warm. The Dietary Manager confirmed that the racks were covered with plastic bags in an attempt to keep the food hot, and acknowledged that the facility only had two insulated meal carts and two metal meal carts available. She also noted that residents in certain halls had complained about cold food, and that the temperature of the food could be affected by the timing of meal tray distribution by CNAs. Test tray sampling revealed that several hot food items were below the required temperature at the point of service, with mashed potatoes on the regular diet tray measured at 123°F and pot roast on the pureed diet tray at 125.9°F, both below the facility's policy requirement of maintaining hot foods at 135°F or higher. The Dietary Manager confirmed that some of the food temperatures were cold and stated that food below the required temperature would be reheated before serving. The facility's policy on safe food handling requires that hot foods be maintained at 135°F or higher and cold foods at 40°F or below at the point of service, which was not consistently achieved during the observed meal service.
Failure to Follow Food Safety Standards in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and service practices that did not comply with professional standards for food safety. Kitchen staff, including one with a short beard, were seen serving and preparing food without required beard restraints, and the Dietary Manager was present in the kitchen without a hairnet. The deep fryer was left uncovered, contained burnt oil, and had food particles around the basket. Several opened food containers in both the food preparation area and dry storage room were not properly sealed, and multiple opened food items in the refrigerator and dry storage were not labeled or dated as required. Interviews with the Dietary Manager and kitchen staff confirmed that staff had been trained on the importance of using hairnets, beard restraints, and proper food storage procedures, including sealing, labeling, and dating opened food items. Despite this training, staff did not consistently follow these protocols, as evidenced by repeated observations of improper food handling and storage. These actions were not in accordance with the facility's own policies and the 2022 Food Code requirements.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility, licensed for 124 beds, failed to employ a qualified full-time social worker as required for facilities of its size. Record review and staff interviews revealed that the only social worker present, Social Worker L, had an expired license and continued to provide social services, including updating and participating in resident care plans. The HR/Payroll Coordinator confirmed that Social Worker L's temporary permit had expired and that the other social worker, Social Worker M, was not a full-time employee and did not provide regular oversight. Social Worker L stated she was the only social worker in the building and was unsure when Social Worker M would be present. Further interviews indicated that facility leadership, including the national director of social services, regional vice president, and previous administrator, were aware of Social Worker L's expired license. Social Worker L continued to work despite knowing her license was expired, citing a lack of other social workers and believing that Human Resources was responsible for monitoring licensure status. The facility's policy required adherence to licensure and educational standards, but these were not met, as Social Worker L provided services without a current license and without full-time qualified coverage.
Failure to Provide and Document Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory training on effective communication for direct care staff, as evidenced by the absence of completed training records for seven staff members, including the Interim Administrator, Interim DON, Med Aide, ADON, and two LVNs. During interviews and record reviews, it was revealed that the HR/Payroll Coordinator, who was new to her role, did not maintain training records in personnel files and was unaware of their location. The ADON, also recently hired, was unable to locate the required training records and had not provided them to the state surveyor as requested. The Corporate Regulatory Specialist, temporarily assigned to the facility, was similarly unaware of the records' whereabouts and was unable to produce them after follow-up attempts. A review of the User Learning Records confirmed that the identified staff members had not completed training on effective communication. Additionally, policies regarding required staff training were requested by the surveyor but were not provided before the survey exit. The lack of documentation and completion of effective communication training for direct care staff constituted the deficiency identified during the survey.
Failure to Ensure Staff Education on Resident Rights and Facility Responsibilities
Penalty
Summary
The facility failed to ensure that all staff members were educated on resident rights and the responsibilities of the facility to properly care for its residents. During interviews and record reviews, it was found that eight out of twelve employees reviewed, including the Interim Administrator, Interim DON, Med Aide, ADON, two LVNs, a Social Worker, and another staff member, did not have documentation of having received the required training on resident rights and facility responsibilities. The HR/Payroll Coordinator, who was new to her role, was unable to locate the training records and was unaware of who maintained them. The ADON, also recently hired, did not know where the training records were kept and was unable to provide them upon request. Further interviews with the Corporate Regulatory Specialist revealed that the training records could not be found, and attempts to compile them were unsuccessful. The facility was unable to provide policies regarding required staff training before the survey exit. A review of the User Learning Records confirmed the absence of documentation for the required training for the identified staff members, some of whom had been recently hired or re-hired. This lack of documentation indicated that the facility did not ensure all staff received the necessary education on resident rights and facility responsibilities.
Failure to Provide and Document Required Abuse and Dementia Training for Staff
Penalty
Summary
The facility failed to provide required annual or new hire training on abuse, neglect, exploitation, misappropriation of resident property, dementia management, and resident abuse prevention for eight out of twelve employees reviewed. These employees included the Interim Administrator, Interim DON, Med Aide, RN, ADON, Social Worker, and others. During interviews and record reviews, it was revealed that the HR/Payroll Coordinator, who was new to her role, did not maintain training records in the personnel files and was unaware of their location. The ADON, also recently hired, was unable to locate the training records and did not know where they were kept. The Corporate Regulatory Specialist, temporarily assigned to the facility, was similarly unaware of the records' location and attempted to follow up with the ADON and corporate office. Despite multiple attempts by facility staff to locate the required training documentation, they were unable to provide evidence that the selected employees had completed the necessary abuse, neglect, exploitation, and dementia care training. The User Learning Records provided did not contain documentation for the required trainings for the identified staff members. Additionally, policies regarding required staff training were requested by surveyors but were not received before the survey exit.
Failure to Provide and Document Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training to all staff on the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program. During interviews and record reviews, it was found that training records for 12 employees, including administrative, nursing, social work, maintenance, and dietary staff, were either missing or could not be located. The HR/Payroll Coordinator, who was new to her role, was unaware of where the training records were kept and did not maintain them in the personnel files. The ADON, also recently hired, was unable to find or provide the requested training documentation. The Corporate Regulatory Specialist, temporarily assigned to the facility, was similarly unaware of the location of these records and attempted to follow up with the ADON and corporate office without success. Despite repeated requests from the state surveyor, the facility was unable to produce documentation showing that the selected staff had received training on the QAPI program. The User Learning Records provided did not include evidence of QAPI training for the identified employees. Additionally, policies regarding required staff training were requested but not received before the survey exit. The lack of documented QAPI training for these staff members constituted a deficiency, as it left staff uninformed about the facility's quality control efforts.
Failure to Provide and Document Mandatory Infection Control Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on infection prevention and control standards, policies, and procedures for 11 of 12 staff members reviewed. During interviews and record reviews, it was revealed that the HR/Payroll Coordinator, who was new to her role, did not maintain training records in the personnel files and was unaware of their location. The ADON, also recently hired, was unable to locate the required training records and was still searching for them during the survey. The Corporate Regulatory Specialist, temporarily assigned to the facility, was also unaware of the location of these records and attempted to follow up with both the ADON and the corporate office. Despite multiple attempts by facility staff to locate the training documentation, the records for the required infection prevention and control training could not be produced for the Interim Administrator, Interim DON, Med Aide, RN, ADON, LVNs, Maintenance, Social Worker, and Dietary Manager. Policies regarding required staff training were requested by surveyors but were not received before the survey exit. The lack of documentation indicated that the facility did not ensure the required infection prevention and control training was provided to the identified staff members.
Failure to Provide and Document Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that all required staff received training in compliance and ethics, as evidenced by the absence of training documentation for eight out of twelve staff members reviewed. These staff included the Interim Administrator, Interim DON, Med Aide, ADON, two LVNs, a cook, and a social worker. During interviews and record reviews, it was revealed that the HR/Payroll Coordinator, who was new to her role, did not maintain training records in the personnel files and was unaware of their location. The ADON, also recently hired, was unable to locate the training records and was still searching for them during the survey. The Corporate Regulatory Specialist, temporarily assigned to the facility, was similarly unaware of where the records were kept and was unable to provide them upon request. Despite multiple attempts by facility staff to locate the required training records, they were unable to produce documentation confirming that the identified staff had completed the mandatory compliance and ethics training. The facility also failed to provide policies regarding required staff training before the survey exit. The User Learning Records reviewed did not show evidence of ethics training for the staff in question, confirming the deficiency in staff training documentation.
Failure to Maintain Behavioral Health Training Records for Staff
Penalty
Summary
The facility failed to maintain a training program to ensure that staff received behavioral health training as required. During interviews and record reviews, it was found that training records for 12 staff members, including the Interim Administrator, Interim DON, Med Aide, RN, ADON, LVNs, Social Workers, Maintenance, and the Dietary Manager, could not be located or provided for review. The HR/Payroll Coordinator, who was new to her role, was unaware of where the training records were kept and did not maintain them in personnel files. The ADON, also recently hired, was unable to locate the records and was still searching for them during the survey. The Corporate Regulatory Specialist, temporarily filling in, was also unaware of the location of the training records and attempted to follow up but was unsuccessful in obtaining the required documentation. Despite multiple attempts by facility staff to locate or compile the necessary training records, the facility was unable to provide documentation that behavioral health training had been completed for the selected employees. Policies regarding required staff training were requested by surveyors but were not received before the survey exit. The lack of documentation and inability to demonstrate compliance with behavioral health training requirements constituted the deficiency cited in the report.
Failure to Ensure Call Light Accessibility for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that two residents had access to their call lights. For one resident with severe cognitive impairment, a history of falls, muscle weakness, and decreased vision, the call light was observed lying on the floor at the foot of the bed and out of reach. The resident's care plan specifically required the call light to be kept in a consistent and repetitive place to promote usage. For another resident, also with severe cognitive impairment, generalized muscle weakness, and a history of falls, the call light was found on the floor by the head of the bed and similarly out of reach, despite care plan interventions directing staff to always keep the call light within reach. Interviews with staff, including a CNA, ADON, and DON, confirmed that all staff members are responsible for ensuring call lights are within reach of residents. The facility's policy also requires staff to place the call light within the resident's reach when leaving the room. These observations and interviews demonstrate that staff did not follow established protocols and care plan interventions, resulting in the call lights being inaccessible to the residents at the time of observation.
Failure to Include Dialysis in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting dialysis care for one resident. The resident, an elderly female with diagnoses including arteriovenous fistula, atherosclerotic heart disease, and hypertension, had physician orders for peritoneal dialysis three times weekly. Despite these orders and documentation of dialysis in the Minimum Data Set (MDS), the resident's comprehensive care plan did not include dialysis or related care instructions. Interviews with facility staff, including the DON, MDS nurse, and regional nurse, confirmed that dialysis should have been included in the care plan to inform staff of the necessary care. The MDS nurse indicated that dialysis was not included because it did not trigger a care area in the MDS, and believed that nurses would follow the orders and communicate relevant information to CNAs. However, both the DON and regional nurse acknowledged that the omission meant the care plan did not fully guide staff in meeting the resident's needs as required by facility policy.
Failure to Provide Required Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary nail care for two residents who were unable to perform activities of daily living independently. One resident, with diagnoses including cerebral infarction, hemiplegia, and muscle weakness, required substantial assistance with personal hygiene and had impairments in mobility and upper body strength. Despite these needs, the resident was observed with long fingernails containing dirt and reported not being offered nail trimming since admission. The care plan included assistance with grooming and hygiene, but this intervention was not carried out as required. Another resident, with generalized muscle weakness, cognitive decline, and aphasia, also required assistance with self-care and had an order for weekly nail checks. This resident was observed with long fingernails, and there was no care plan addressing personal hygiene. Staff interviews revealed that nail care was scheduled weekly but could be provided as needed, and that refusals were to be documented. However, there was no evidence that nail care was consistently offered or refusals properly documented. Facility policy required necessary care for residents unable to perform ADLs, but this was not followed, resulting in the deficiency.
Failure to Provide Routine Dental Services to Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance to a resident who required dental care. The resident, a female with quadriplegia, dysphagia, and a disorder of tooth development, was dependent on staff for all activities of daily living, including oral care. Her care plan indicated that staff should provide oral care assistance according to her abilities. Despite this, records showed that her last dental visit was for an emergency exam after losing a crown, during which it was noted that her oral hygiene needed improvement and she required a deep cleaning in a hospital setting. The resident reported sensitivity and bleeding during oral care, and she had requested dental services from both nursing staff and the previous administrator since her last dental visit. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for monitoring and scheduling dental appointments. The CNA stated that oral care was performed by CNAs and nursing staff, and that residents either went out for dental services or were seen by a dentist in the facility, with the last visit occurring several months prior. The DON and social worker both indicated that social services were responsible for monitoring dental appointments, but neither was certain about the frequency of dental visits or the process for monitoring effectiveness and dentist availability. The social worker also stated she had not received any reported concerns or requests for dental appointments, and that such requests would be discussed in meetings, but she was unsure how the process was tracked. Facility policy required staff to provide a list of dental care providers upon admission and to assist with scheduling appointments and transportation as needed. However, interviews and record reviews indicated that the resident's requests for dental care were not effectively addressed, and there was no clear documentation or follow-up to ensure routine dental services were provided. This lack of coordination and follow-through resulted in the resident not receiving the routine dental care she required.
Failure to Perform Hand Hygiene During Perineal Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to perform proper hand hygiene during perineal care for a female resident with severe cognitive impairment, dementia, and generalized muscle weakness. The resident required extensive assistance with toileting and was dependent on staff for activities of daily living. During an observed episode of perineal care, the CNA disposed of dirty wipes and gloves and then put on new gloves to place clean briefs on the resident without performing hand hygiene in between these steps. Interviews with facility staff, including the CNA, Director of Nursing (DON), and Assistant Director of Nursing (ADON), confirmed that hand hygiene should be performed after removing soiled gloves and before donning new gloves and handling clean briefs. The facility's policy and referenced nursing procedures also required hand hygiene at these points. The failure to follow these procedures was observed directly and acknowledged by staff as not in accordance with infection prevention and control protocols.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents across all four hallways reviewed for infection control. Observations revealed trash, including medical gloves, food, and paper, scattered on the floors of various rooms and hallways. Notably, bloody gauze was found on the floor in hall 400, which was acknowledged as an infection control issue by LVN I. The Interim-DON confirmed that biohazard materials should be disposed of by nursing staff, followed by disinfection by housekeeping. Interviews with staff, including the Interim-DON, Manager of Housekeeping, and RN E, highlighted a lack of clarity and consistency in responsibilities for trash and biohazard disposal. The Manager of Housekeeping stated that his team was responsible for non-fluid trash during their working hours, while nursing staff were responsible for biohazard materials. However, outside of housekeeping hours, nursing staff were expected to manage all trash and spills. This inconsistency in roles and responsibilities contributed to the observed deficiencies. The facility's policy on maintaining a clean and dignified environment was not adhered to, as evidenced by the presence of trash and biohazard materials on the floors. Staff interviews consistently pointed out the risk of infection due to the failure to promptly and properly dispose of trash and biohazard materials. The report indicates that the facility's environment did not meet the standards set by their own policy, potentially compromising resident safety and comfort.
Failure to Assess Bed Rail Risk for Resident
Penalty
Summary
The facility failed to assess a resident for the risk of entrapment from a bed rail prior to its installation, which is a deficiency in the care provided. The resident, who was diagnosed with dementia and had a history of falls, did not have a Bed Rail Assessment completed to ensure the appropriateness of the bed rails for their needs. Additionally, there were no orders for the use of bed rails documented in the resident's records, and the use of bed rails was not included in the resident's care plan. The deficiency was identified through observation, interviews, and record reviews. The resident reported using the bed rails to get up independently and mentioned an incident where their wrist hit the bed rail, causing swelling and pain. This incident led to a medical evaluation, which revealed a fracture. Interviews with facility staff, including the Interim-DON, EX-DON, and Nurse Assessment Coordinator, confirmed that there were no orders or assessments for the bed rail use, and the staff acknowledged the necessity of such assessments to prevent risks like entrapment. The facility's policy on bed rails and side rails requires an evaluation for the risk of entrapment before installation and mandates that qualified staff assess the need for bed rails based on specific criteria. However, the policy was not followed in this case, as evidenced by the lack of assessment and orders for the resident's bed rail use. The failure to adhere to these procedures could place residents at risk of injury from inappropriate or unnecessary enablers.
Inaccurate MDS Assessment for Bed Rail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident regarding the use of bed rails. Specifically, the quarterly MDS for a resident did not indicate the use of bed rails, despite observations and interviews confirming their presence. The resident, who was diagnosed with dementia and had a history of falls, was observed using bed rails during a demonstration of his ability to turn in bed. However, the MDS assessment did not include this information in Section P, which covers restraints and alarms. Interviews with facility staff, including the Interim Director of Nursing (DON), the former DON, and the Nurse Assessment Coordinator, revealed a lack of awareness and understanding regarding the necessity of coding bed rail use in the MDS assessment. The Interim DON and the Nurse Assessment Coordinator were unsure of the risks associated with not coding the bed rail use, while the former DON acknowledged that the resident should have been coded for bed rail use. This oversight in the MDS assessment could potentially place residents at risk of not receiving adequate care.
Failure to Implement Comprehensive Care Plan for Bed Rail Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident's use of bed rails, which are considered enablers. This deficiency was identified during a review of the resident's records, which showed that the care plan did not include the use of bed rails, despite the resident having a history of dementia and falls. The resident was observed demonstrating how his wrist hit the bed rail while turning in bed, indicating the need for a care plan that addresses the use of bed rails. Interviews with facility staff, including the Interim-DON, EX-DON, and Nurse Assessment Coordinator, revealed that the care plan should have included the use of bed rails to ensure proper care and safety for the resident. The staff acknowledged that the absence of this information in the care plan could pose a risk, as it would leave the nursing staff unaware of how to properly care for the resident. The facility's policy requires the development of a comprehensive care plan that meets professional standards of quality, which was not adhered to in this case.
Failure to Engage Brakes on Mechanical Lift During Resident Transfer
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent accidents for a resident requiring mechanical lift assistance. During an observation, two CNAs were seen using a mechanical lift to transfer a resident without engaging the brakes, causing the lift to move slightly. This oversight occurred despite the CNAs having received training on proper mechanical lift procedures, which included securing the brakes to prevent movement during transfers. The resident involved was an elderly male with severe cognitive impairment and multiple mobility-related diagnoses, including muscle wasting and paralytic gait, necessitating extensive assistance for bed mobility and transfers. The facility's policy on mechanical lifts emphasized performing safety checks and ensuring the stability of equipment before lifting, which was not adhered to in this instance. Interviews with the CNAs and the former Director of Nursing confirmed the lapse in following established safety protocols, highlighting a failure in maintaining a hazard-free environment for residents requiring mechanical lift transfers.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of Cilostazol, a vasodilator medication prescribed for essential primary hypertension. The medication was not administered on a specific date due to its unavailability, as noted in the Medication Administration Record (MAR). The medication was ordered to be given twice daily, but the facility did not have it on hand, and there was no documentation of any follow-up actions taken to address the unavailability. Interviews with staff revealed a lack of recollection regarding the specific resident and the actions taken when the medication was unavailable. The resident involved was an elderly female with a history of diabetes, hypertension, and strokes, which could increase the risk of complications from missed doses of blood pressure medication. The facility's policies required that medications be administered as ordered and that any issues with medication availability be documented and reported to the physician. However, there was no evidence that the physician was notified or that alternative measures were taken to ensure the resident received the necessary medication. This deficiency in pharmaceutical services could potentially place residents at risk for medical complications due to missed doses.
Deficiencies in Resident Documentation and Care Planning
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in documentation. For one resident, the facility did not document the resident's request to transfer to another facility. Despite the resident's cognitive intactness and clear communication of her desire to transfer, the request was not recorded in her progress notes. The Director of Nursing (DON) acknowledged the oversight, stating that the request should have been documented, and the Business Office Manager (BOM) was involved in the transfer process but did not document the request either. This lack of documentation could lead to missing or misleading information affecting resident care. Another resident's care plan contained an error regarding the use of eyeglasses. The care plan inaccurately stated that the resident should be wearing eyeglasses, although the resident did not use them. The Licensed Vocational Nurse (LVN) responsible for the care plan admitted to the mistake and acknowledged that the inaccurate information could be misleading. The DON confirmed that nurses are trained to modify care plans based on resident needs and that the care plan must be accurate to ensure appropriate care. The facility's policies on discharge planning and documentation guidelines emphasize the importance of accurate and complete documentation. The failure to document the transfer request and the incorrect care plan entry highlight lapses in adhering to these policies. The Administrator reiterated the expectation for accurate documentation to prevent gaps in information that could impact resident care.
Facility Lacks Full-Time Social Worker, Affecting Resident Services
Penalty
Summary
The facility, licensed for 124 beds, failed to employ a qualified social worker on a full-time basis since August 5, 2024. This deficiency was identified through interviews and record reviews, revealing that the Director of Nursing (DON) and other management staff were handling the social worker's duties. The absence of a social worker led to issues such as grievances not being properly addressed and discharge planning being inadequately managed. Resident #1's family member reported a grievance that was not handled by a social worker, and Resident #6 experienced a failed transfer request due to the lack of follow-up by the facility staff. The Administrator, who was newly hired on July 29, 2024, confirmed that the social worker's last day was August 2, 2024, and that the position had been posted online since July 8, 2024. Despite the ongoing recruitment process, the facility had not yet filled the position, resulting in increased workloads for existing management staff. The Administrator acknowledged the challenge of not having a social worker available for residents and families, and a potential candidate was scheduled for an interview on August 26, 2024.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide timely notification to the Office of the State Long-Term Care Ombudsman regarding the transfer or discharge of a resident. Specifically, the facility did not send a written notice of transfer or discharge for a resident who was discharged home. This oversight was identified during a review of the resident's records and communication with the Ombudsman, who confirmed that they had not received any notification about the resident's discharge. The Ombudsman also noted that they had not received a monthly discharge list from the facility for several months, which is a requirement. Interviews with facility staff revealed a lack of clarity regarding the responsibility for sending discharge notices to the Ombudsman. The social worker, who was newly hired, was unaware of the requirement, and the Director of Nursing (DON) believed it was the social worker's responsibility. The Administrator also stated that the social worker should be responsible for contacting the Ombudsman. The facility's policy, dated March 2021, clearly states that a copy of the notice should be sent to the Ombudsman at the same time it is provided to the resident and their representative.
Failure to Ensure Fall Mat Placement for High-Risk Resident
Penalty
Summary
The facility failed to ensure that Resident #7's fall mat was positioned bedside while the resident was lying in bed. This failure was observed during an interview and observation on 05/22/2024, where Resident #7 was found lying in bed with the fall mat folded and leaning against an unoccupied bed in the room. Resident #7, a [AGE] year-old male with diagnoses including unsteadiness on feet, hypotension, dementia, and other conditions, had a history of falls and was assessed as high risk for falls. The resident's care plan included the use of a fall mat to reduce the severity of injuries if the resident fell from the bed. However, the mat was not in place as required, which could place the resident at risk of falls and injuries. During interviews, LVN I and the DON confirmed that Resident #7 was a high-risk fall patient and that the fall mat should be in place anytime the resident was in bed. LVN I was observed placing the mat on the floor next to Resident #7's bed after it was found folded and leaning against another bed. Both LVN I and the DON acknowledged that staff members responsible for checking on residents should ensure that fall prevention measures, including the use of fall mats, are in place. The facility's policy on Fall Management also indicated that individualized interventions should be reassessed and revised as needed to manage falls, but this was not adhered to in Resident #7's case.
Failure to Post Oxygen Sign for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care was provided with appropriate care consistent with professional standards. Specifically, the facility did not post an oxygen sign outside the resident's room, which is necessary to inform staff and visitors of the presence of oxygen and to prevent fire hazards. The resident, an elderly female with severe cognitive impairment and a diagnosis of acute respiratory failure with hypoxia, was observed using oxygen therapy without the required signage. This oversight was confirmed during interviews with the RN and the DON, both of whom acknowledged the necessity of the sign and the responsibility of the Charge Nurse to ensure it was posted. The resident's care plan and physician orders indicated the need for intermittent oxygen therapy at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%. Despite these documented needs, the absence of the oxygen sign was noted during an observation. The facility's policy on oxygen administration also mandates the placement of an oxygen precautions sign if required, which was not adhered to in this case. This failure could potentially expose residents on oxygen therapy to fire hazards if staff and visitors are unaware of the oxygen presence.
Inaccurate Nursing Documentation for Fall Risk Assessment
Penalty
Summary
The facility failed to ensure accurate nursing documentation for a resident, leading to potential errors in treatment. The resident, a male with multiple diagnoses including unsteadiness on feet, acute embolism, hypotension, dementia, anxiety, insomnia, and bipolar disorder, was assessed as having a high risk for falls. However, a fall risk assessment completed by a nurse inaccurately documented the resident as low risk for falls with no history of falls, despite the resident's care plan and previous assessments indicating a high fall risk. During an interview, the Director of Nursing (DON) confirmed that the resident was indeed a high fall risk and had experienced falls in the facility. The DON acknowledged the incorrect assessment and expressed uncertainty about why the nurse documented the resident as low risk. The facility's policy on fall management requires accurate fall risk evaluations to identify appropriate preventative interventions, which was not adhered to in this case.
Failure to Conduct Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not conduct neurological checks for two residents after they experienced falls. Resident #3, a male diagnosed with dementia, anxiety, muscle weakness, lack of coordination, and epilepsy, had a fall on 02/25/24. Despite the fall being unwitnessed, no neurological checks were performed as per the facility's protocol. The Director of Nursing (DON) confirmed that neurological checks should have been conducted for unwitnessed falls or suspected head injuries, but this was not done for Resident #3. Similarly, Resident #5, a male diagnosed with dementia, cataracts, osteoporosis, and seizures, experienced a fall on 03/13/24. The resident was found on the floor in the dining area and expressed pain, but no neurological checks were completed as required by the facility's policy. Interviews with the Assistant Director of Nursing (ADON) and a Licensed Vocational Nurse (LVN) confirmed that neurological checks should be performed for unwitnessed falls or head injuries to prevent potential complications such as subdural hematoma. The facility's policies on neurological checks and fall management clearly state that neurological evaluations should be performed for residents who sustain unwitnessed falls, regardless of their cognitive status. However, the facility failed to adhere to these policies for both Resident #3 and Resident #5, thereby placing them at risk of undetected head injuries and other complications. This failure to conduct necessary neurological checks represents a significant deficiency in the care provided to these residents.
Failure to Use Hoyer Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure that Resident #1's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, the facility did not use the Hoyer lift to transfer Resident #1, who required a two-person Hoyer lift transfer due to her medical conditions, including quadriplegia, dementia, and chronic pain. Instead, CNA B attempted to transfer Resident #1 alone, which led to an incident where Resident #1 slipped and nearly fell while being moved to a shower chair. Resident #1's medical records indicated that she was dependent on facility staff for all activities of daily living and required a two-person Hoyer lift for transfers. Despite this, CNA B attempted a one-person transfer, which was against the care plan and facility policy. During the transfer, the shower chair moved, causing Resident #1 to slip. CNA B then called for assistance from LVN A, who helped complete the transfer. Resident #1 reported hitting her head and experiencing pain, although no injuries were noted upon assessment. Interviews with facility staff, including CNA B, LVN A, the DON, and the DOR, confirmed that Resident #1 was a two-person Hoyer lift transfer and that CNA B had not followed the proper procedure. CNA B admitted to not thinking clearly and attempting the transfer alone, which was inappropriate given Resident #1's condition. The facility's policies on fall management and mechanical lifts were not adhered to, leading to the incident and placing Resident #1 at risk of injury.
Improper Handling of Catheter Drainage Bag
Penalty
Summary
The facility failed to establish and maintain an infection control program, as evidenced by the improper handling of a catheter drainage collection bag for one resident. Resident #4, who has a history of hepatitis C and chronic kidney disease, was observed with their catheter drainage collection bag lying flat on the floor next to their bed on multiple occasions. The resident's care plan specifically instructed that the collection bag should be stored inside a protective pouch and not allowed to touch the floor. However, these instructions were not followed, as observed on two separate occasions on the same day. The resident was unable to provide details about the situation due to their condition of being rarely/never understood, as noted in their quarterly MDS assessment. Interviews with the facility staff, including an LVN and the DON, confirmed that the drainage collection bag should never be left on the floor due to the risk of infection. Both staff members acknowledged that it is the responsibility of CNAs and nurses to ensure the proper positioning of the drainage bag. The facility's infection control policy and urinary catheter maintenance policy both emphasize the importance of not placing the drainage bag on the floor to reduce the risk of contamination and catheter-associated urinary tract infections (CAUTI). Despite these policies, the deficiency was observed, indicating a lapse in adherence to established infection control protocols.
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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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