Mid Valley Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Mercedes, Texas.
- Location
- 601 N Mile 2 West, Mercedes, Texas 78570
- CMS Provider Number
- 676414
- Inspections on file
- 33
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Mid Valley Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident receiving IV Vancomycin was given a scheduled dose before the ordered trough level was obtained, and the lab draw was not completed as scheduled. Another resident with HTN and prior CVA had multiple doses of Amlodipine, Carvedilol, and Losartan held by MAs even though the resident's BP and pulse were within the physician's ordered parameters; staff cited confusion from conflicting hold parameters in the chart.
A resident with ESRD, dialysis dependence, and hypotension had an incorrect Midodrine order that included a hold parameter for SBP less than 140. The LVN followed the order as written, entered a code 3, and did not send the medication to the dialysis clinic. The NP and DON stated the order should not have had parameters and that the medication was intended to be sent with the resident for use during dialysis if BP dropped.
Medication Administration Error Rate Exceeded 5 Percent: Surveyors found an 8.11% med error rate after an MA failed to give a resident’s ordered anti-hypertensive meds because she relied on a diastolic BP parameter that was not in the active orders. The resident had HTN and a history of stroke, and her orders required holding the meds only if SBP was below 100, with Carvedilol also held if pulse was below 60. The LVN, ADON, and DON stated the meds should not have been held based on the resident’s vital signs and that older hold parameters in pharmacy comments were confusing but not part of the order.
Expired and unlabeled food was found in a resident's personal refrigerator. The refrigerator contained sealed pudding cups past the expiration date and a half-eaten cupcake without an open or expiration date. The resident had Alzheimer’s disease, a BIMS of 5, and severe cognitive impairment. Staff reported they checked refrigerator temperatures, but one housekeeper said she did not check food dates and had not been told to do so, while the facility policy required outside food to be labeled and handled properly.
Inadequate Hand Hygiene During Medication Administration: A MA did not perform hand hygiene for at least 20 seconds before giving meds to one resident and did not perform hand hygiene for at least 20 seconds before and after giving meds to another resident. One resident had severe cognitive impairment, and the other was cognitively intact. The facility policy addressed infection prevention and control but did not specify hand washing procedures.
A resident with dementia and other medical conditions had an authorization form signed by the responsible party requesting a complete copy of the medical record. An LVN in medical records forwarded the request to the Health Information Management (HIM) Director, who assumed responsibility for compiling and emailing the full chart. The HIM Director later reported she believed she had sent the records via secure email but could not find any email or confirmation showing they were sent, while the LVN was unsure of the required time frame for fulfilling such requests. Facility policy required access to records within 24 hours of request and fulfillment of copy requests within two working days, but the resident’s responsible party did not receive the requested records as required.
A resident with CHF, chronic pulmonary edema, dementia, and other comorbidities had physician orders for continuous O2 at 2 L via nasal cannula and a care plan addressing oxygen therapy, but the plan did not include her repeated behavior of removing the nasal cannula and being non‑compliant with O2. Multiple staff, including CNAs, LVNs, and the RT, reported that the resident frequently or constantly removed her oxygen and required staff to repeatedly replace it and monitor her. The MDS nurse and DON acknowledged that this behavior was known to staff and should have been included on the care plan, but it was not, and facility policies on oxygen administration and care plans did not specifically address documenting such behaviors.
A resident with dementia, diabetes, and trauma-related pain had a PRN acetaminophen order and was documented in a nurse’s note as having received the medication for back pain after a fall, but the August MAR contained no corresponding nurse signature or entry showing it was administered. The LVN later stated she likely forgot to document the dose on the MAR despite prior training on MAR/TAR use, and the DON confirmed the medication should have been signed off and that the MAR did not show administration, while the facility’s medication administration policy lacked specific language on documenting administered medications in the MAR.
A resident with multiple medical conditions had a documented DNR status in her records, but the facility failed to obtain the required physician's signature on the Out-of-Hospital Do Not Resuscitate (OOH-DNR) form. Staff interviews confirmed that, despite the DNR status being noted electronically and a verbal order from the physician, the official OOH-DNR form was incomplete, lacking the physician's signature as mandated by facility policy.
A resident with multiple medical conditions, including diabetes and dehydration, was found with a peripheral IV lock covered by a transparent dressing that was not dated or initialed, contrary to facility policy and standard nursing practice. Nursing staff and the DON confirmed that the dressing should have been labeled to track placement and changes, but documentation was lacking and the responsible nurse could not recall recent IV administration training.
A normal saline flush was found left at the bedside of a cognitively impaired resident, rather than being stored in a locked compartment as required. Facility staff confirmed that medications should not be accessible at the bedside, and facility policy mandates secure storage of all drugs and biologicals.
A CNA was observed reusing wipes multiple times while providing perineal and catheter care to a male resident with a Foley catheter, and performed the care with the resident standing, causing discomfort. Staff interviews revealed inconsistencies in training and understanding of proper technique, and facility policies lacked clear guidance on the use of wipes versus washcloths.
A resident with a history of pruritus and behaviors of itching and scratching did not have these issues reflected in their care plan, despite staff awareness, medical documentation, and ongoing treatment. The care plan only included general skin risk statements and omitted specific interventions or objectives related to the resident's pruritus, contrary to facility policy and staff acknowledgment that such conditions should be documented.
A resident with multiple complex medical conditions did not have a physician-ordered weekly total body skin assessment documented as required. The Treatment Nurse, who was responsible for these assessments, was absent, and the DON, who assumed responsibility, failed to document the assessment in the medical record. Both staff members had been deemed competent in skin assessment and documentation, and facility policy required weekly documentation, but the required record was missing for the specified week.
A resident with a history of renal failure and fractures experienced a fall, prompting neuro checks as per protocol. However, four nurses failed to accurately document these checks, with repeated vital signs entries showing the same readings and dates. Interviews revealed that the nurses noted vitals on paper but did not update the electronic records, leading to discrepancies. The DON confirmed the errors but noted no negative effects on the resident.
A facility failed to include oxygen treatment in a resident's care plan, despite the resident using oxygen daily. The resident, with a history of serious medical conditions, was observed using oxygen without a corresponding care plan. Staff interviews revealed that the MDS coordinator had not received a physician's order for the oxygen, leading to its omission from the care plan, contrary to facility policy.
The facility failed to ensure proper respiratory care for two residents, as both were receiving oxygen therapy without physician orders and lacked appropriate signage. One resident, a male with severe cognitive impairment, was using oxygen without a posted sign, while a female resident with a history of strokes and heart failure also lacked a physician's order for her oxygen therapy. Staff interviews revealed a lack of clarity in responsibilities for managing physician orders and posting oxygen signs, leading to these deficiencies.
The facility did not comply with food service safety standards by failing to label and date food items in the freezer. An open bag of French toast was found unlabeled and undated, exposing it to air. A staff member admitted to not knowing how long it had been there and acknowledged the importance of labeling to prevent contamination. The Dietary Manager confirmed that all staff are responsible for this task, as per facility policy.
A facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents. An LVN did not follow Enhanced Barrier Precautions (EBP) while administering medication via a G-tube to a resident, wearing only gloves instead of the required gown and gloves. Additionally, the facility did not inform visitors that another resident was on contact precautions due to an ESBL infection, and no precaution sign was posted on the resident's door. These lapses in protocol could lead to cross-contamination and infection spread.
A resident with severe cognitive impairment experienced neglect during a Foley catheter change when LVN D and LVN R failed to stop the procedure despite the resident's cries of pain. The resident, who had multiple medical conditions, was subjected to continued catheter insertion, leading to significant discomfort and eventual hospital transfer due to hematuria. The nursing staff did not adhere to protocols requiring cessation of the procedure when a resident expresses pain.
A resident with severe cognitive impairment experienced pain during a Foley catheter change, but the LVNs involved did not stop the procedure despite the resident's cries for help. The resident, who had a history of urinary tract infection, hematuria, and dementia, was hospitalized due to hematuria. The facility failed to implement its abuse prevention policies, leading to Immediate Jeopardy.
A resident with severe cognitive impairment and a history of wandering exited a facility undetected and was found in the parking lot near a busy street. Despite previous observations of the resident's exit-seeking behavior, the care plan did not address these behaviors until after the incident. The facility lacked adequate monitoring and did not report the incident to the state, as the resident was not considered missing.
A resident with a urinary catheter experienced pain and hematuria during a catheter change when LVNs failed to stop the procedure despite resistance and the resident's cries of distress. The resident, with a history of UTIs and dementia, was sent to the hospital for evaluation. The facility's failure to notify the doctor and address the resident's discomfort led to an Immediate Jeopardy situation.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised and was found in the parking lot. Despite being quickly redirected back inside without injury, the incident was not reported to the state within the required 24-hour timeframe. The facility's Administrator and DON did not report the incident, citing corporate guidelines, despite the facility's policy requiring such reporting.
A facility failed to update the care plan for a resident with dementia who exhibited wandering and exit-seeking behaviors. Despite these behaviors being documented in progress notes and discussed with the resident's responsible party, the care plan was not revised to include interventions until several months later. This oversight could have led to missed or delayed continuity of care.
A resident with multiple serious health conditions did not receive his prescribed heart failure medication, Entresto, due to its unavailability. The responsible nurse failed to notify the doctor or pharmacy, despite being aware of the protocol. The facility's Director of Nursing acknowledged the lapse in following the policy for timely medication administration.
Medication Administration Errors With IV Antibiotic and Antihypertensive Orders
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 2 of 5 residents reviewed for medication errors. One resident, who had acute respiratory failure with hypoxia, a tracheostomy, and ventilator-associated pneumonia, was ordered IV Vancomycin every 12 hours and also had a Vancomycin trough scheduled for 04/08/26. The resident received the 8:00 a.m. Vancomycin dose before the trough level was obtained, and the laboratory logbook showed the blood draw was not completed that morning. The ADON stated the lab was short staffed, the trough was not collected, and the nurse should not have administered the Vancomycin without the level being drawn. The second resident, who had hypertension, cerebral infarction, aphasia following cerebral infarction, dysphagia following cerebral infarction, and other sequelae of cerebral infarction, had orders for Amlodipine, Carvedilol, and Losartan Potassium with hold parameters based on systolic blood pressure and, for Carvedilol, pulse. Review of the MAR showed multiple missed opportunities when medication aides held these medications even though the resident's blood pressure and pulse were within the physician's ordered parameters. The missed administrations involved the morning dose of Amlodipine, the morning and evening doses of Carvedilol, and the morning, evening, and bedtime doses of Losartan Potassium across multiple dates in March and April 2026. Interviews showed that MA D held the medications because the resident's diastolic blood pressure was below 60 and because she saw conflicting hold parameters in the chart. LVN E stated the orders only required holding the medications if systolic blood pressure was below 100, and that MA D should not have held them. The ADON stated old hold parameters remained in the pharmacy comments area and were not removed when the physician updated the orders, which could make it appear there were two sets of hold parameters. The DON stated that if blood pressure medications were held when they should have been given, the resident's blood pressure could become too high and lead to stroke.
Incorrect Midodrine Order and Missed Dialysis Medication
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of Resident #6 when the facility failed to ensure the physician’s Midodrine order was correct. Resident #6 was a male with end stage renal disease, dependence on renal dialysis, and hypotension. His MDS reflected intact cognition with a BIMS score of 15. His care plan noted that he received dialysis on Mondays, Wednesdays, and Fridays and that medications were to be given as ordered by his physician. The physician’s order summary dated 04/09/26 reflected Midodrine HCI 5 mg, one tablet by mouth one time a day every Monday, Wednesday, and Friday for hypotension on dialysis days, with instructions to hold if systolic blood pressure was less than 140 and notify the nurse/MD. On 04/08/26, the MAR showed the Midodrine was not administered and a code 3 was entered for medication held because blood pressure was outside parameters. During interview, the NP stated the hold parameter was not correct and that the order should not have had any parameters; he said the medication should have been sent with the resident to the dialysis clinic regardless of blood pressure. The DON stated the resident’s Midodrine was intended to be sent to the dialysis clinic in case his blood pressure dropped, and that the dialysis clinic did not keep medications on hand. She also stated the order was not correct and should not have had parameters, but the LVN followed the order as written and did not send the medication with the resident. The dialysis RN confirmed the facility was to send a labeled Midodrine pill with the dialysis communication sheet, and the dialysis communication form for that treatment reflected asymptomatic hypotension during treatment with a request to send Midodrine with the patient.
Medication Administration Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure its medication error rate was not 5 percent or greater. Surveyors found an 8.11% medication error rate, based on 3 errors out of 37 opportunities, involving 1 of 5 residents observed during medication administration. The deficiency centered on a medication administration error for a resident with a history of hypertension, cerebral infarction, aphasia following cerebral infarction, dysphagia following cerebral infarction, and other sequelae of stroke. Her quarterly MDS reflected a BIMS score of 15, indicating she was cognitively intact. The resident’s care plan addressed heart disease and risk for complications including chest pain, shortness of breath, edema, and high blood pressure, with interventions to administer medications as ordered and monitor vital signs as indicated. Her physician’s orders included Amlodipine Besylate 10 mg daily, Carvedilol 12.5 mg twice daily, and Losartan Potassium 50 mg twice daily, each with hold parameters based on systolic blood pressure, and Carvedilol also based on pulse. During observation, the resident’s blood pressure was 122/53 and pulse was 64, but the MA did not administer the three anti-hypertensive medications. During interview, the MA stated she held the medications because the diastolic blood pressure was below 60, and she believed the resident was outside the parameters for administration. The LVN and ADON stated the active physician orders only required holding the medications if systolic blood pressure was below 100, with Carvedilol also held if pulse was below 60, and that the MA should not have held the medications. The ADON explained that older hold parameters remained in the pharmacy comments area and could appear confusing, but were not part of the administration order. The DON stated the medications were later given after the nurse contacted the nurse practitioner.
Expired and Unlabeled Food Found in Resident Refrigerator
Penalty
Summary
The facility failed to enact a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for Resident #43. During observation, Resident #43's personal refrigerator contained 3 small sealed cups of pudding with an expired date of 12/10/25 and a half-eaten carrot cupcake that did not have an open date or expiration date. The resident's refrigerator temperature log was posted next to the refrigerator and showed it had last been checked on 04/07/26 in the AM. Resident #43's record showed diagnoses including Alzheimer's Disease Unspecified, Essential Hypertension, Gastro-Esophageal Reflux Disease without Esophagitis, Hyperlipidemia, and Cognitive communication deficit. The quarterly MDS assessment showed a BIMS of 5, indicating severe cognitive impairment. In interview, Resident #43 stated he did not know when the food items were brought. Housekeeper A stated she checked the refrigerator temperature when cleaning the room but did not check food dates and had not been told to do so. The Housekeeping Supervisor stated housekeeping staff were responsible for checking residents' personal refrigerators and were told to check temperatures, expiration dates, and label open dates. The ADM stated housekeeping checked residents' personal refrigerators daily and that expiration dates should be checked. The facility's Outside Foods policy stated outside food should be labeled with the resident's name and date and that proper food handling should be used once outside food is brought into the facility.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility did not maintain hand hygiene practices during medication administration for two residents. Resident #14 was an [AGE] year-old male admitted with diagnoses including unspecified dementia, paroxysmal atrial fibrillation, type 2 diabetes mellitus, hyperlipidemia, essential hypertension, and cognitive communication deficit. His quarterly MDS reflected a BIMS score of 3, indicating severe cognitive impairment. During observation, MA D scrubbed her hands for 8 seconds before administering medication to Resident #14, rather than the at least 20 seconds reflected in CDC guidance. Resident #82 was an [AGE] year-old female admitted with diagnoses including fracture of the right patella, type 2 diabetes mellitus, hyperlipidemia, essential hypertension, and long term use of anticoagulants. Her admission MDS reflected a BIMS score of 15, indicating she was cognitively intact. During observation, MA D scrubbed her hands for 8 seconds before administering medication to Resident #82 and scrubbed her hands for 11 seconds after administering medication to Resident #82. In interview, MA D stated hands were washed for 30-35 seconds total and that she was counting scrub time, not total time. The ADON stated hand washing scrub time was supposed to be at least 20 seconds, and the DON stated infection control was in-serviced all the time. The facility policy reflected staff responsibilities for infection prevention and control, but did not specify hand washing procedures.
Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to timely access to personal and medical records. A male resident with unspecified dementia, moderate cognitive impairment (BIMS score of 09), type 2 diabetes mellitus, and acute pain due to trauma was admitted and later discharged from the facility. His care plan reflected impaired cognitive function related to dementia. After discharge, the resident’s responsible party (RP) completed and signed an authorization to disclose protected health information form requesting the resident’s medical records. On the date of the request, the Medical Records LVN received the RP’s request for the resident’s records and forwarded it to the Health Information Management (HIM) Director. The LVN reported that, because the family requested the entire chart, the HIM Director decided she would handle compiling and emailing the records directly to the RP. The LVN stated she typically provided records such as medication lists after clearance from the HIM Director, but in this case, the HIM Director took responsibility for sending the full chart. The LVN was unsure of the exact time frame required to send requested records and indicated she would need to review facility policy, though she believed records were usually sent timely. The HIM Director stated she had completed gathering the requested records and believed she had sent them via secure email, which normally generated a confirmation receipt. However, upon reviewing her email, she found no record of sending the resident’s requested records and no confirmation receipts. She acknowledged having multiple record requests at that time and could not locate any evidence that the records for this resident had been sent. The facility’s policy stated that residents have the right to access all records pertaining to their care within 24 hours of an oral request followed by a signed written request, and that requests to purchase copies of records would be granted within two working days. Despite this policy, the requested records were not provided to the resident’s RP as required.
Failure to Care Plan Resident’s Repeated Removal of Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who required continuous oxygen therapy received care consistent with professional standards of practice and a comprehensive, person-centered care plan. The resident was an older female with diagnoses including unspecified dementia without behavioral disturbance, type 2 diabetes mellitus, combined systolic and diastolic congestive heart failure, chronic pulmonary edema, and paroxysmal atrial fibrillation. A 5‑day MDS showed she was cognitively intact with a BIMS score of 14. Physician orders directed continuous oxygen at 2 L via nasal cannula, and the care plan included a focus on oxygen therapy related to CHF with an intervention to administer oxygen per MD orders. Despite this, the care plan contained no language addressing the resident’s behavior of removing her nasal cannula or non‑compliance with oxygen therapy. Multiple staff interviews confirmed that the resident frequently removed her oxygen. An LVN stated the resident would occasionally remove her oxygen and that nurses and the respiratory therapist would replace it when notified by CNAs or during rounds. A CNA reported that the resident removed her oxygen and that staff repeatedly put it back on, only for the resident to remove it again. Another LVN described the resident as constantly removing her oxygen and needing frequent correction. The respiratory therapist reported that the resident was always taking off her oxygen and that staff were constantly checking to ensure it was on, with this behavior being communicated in report. The MDS nurse acknowledged that staff had reported the resident sometimes removed her oxygen and needed reminders, and he stated that this behavior should have been on the care plan but was not, explaining that he relied on behavior reports, particularly after the resident’s readmission, to update care plans. The DON also stated that the resident had continuous oxygen orders and had previously been known to constantly remove her oxygen, and that staff were aware and had to monitor her. Both the MDS nurse and the DON stated that the behavior of removing oxygen should have been on the care plan, but it was not included, and facility policies on oxygen administration and care plans did not contain specific language about documenting such behaviors on the care plan.
Failure to Accurately Document PRN Pain Medication on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident who had dementia with moderate cognitive impairment, type 2 diabetes mellitus, and acute pain due to trauma. The resident’s care plan identified a risk for discomfort or pain related to immobility, with an intervention to administer pain medication as recommended by the physician. A physician’s order was in place for PRN acetaminophen 650 mg by mouth every 6 hours as needed for pain, not to exceed 3000 mg in 24 hours. Nursing documentation on the same day indicated that the resident complained of back pain after a fall and was provided PRN acetaminophen. However, review of the resident’s August medication administration record (MAR) showed that the PRN acetaminophen order was entered with a start time but had no nurse signature or indication that the medication was administered, despite the nurse’s progress note stating it had been given. During interview, the LVN acknowledged that if she administered the medication, she was responsible for documenting it on the MAR and stated she probably forgot to click it as administered. She confirmed she had been trained on medication administration documentation and understood that failure to document could affect subsequent nurses’ knowledge of prior doses. The DON confirmed that the medication should have been signed off on the MAR, that LVN A was responsible for the documentation, and that the MAR did not reflect administration. Review of the facility’s medication administration policy showed no specific language regarding documentation of administered medications in the MAR.
Failure to Obtain Physician Signature on OOH-DNR Form
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was properly completed, specifically lacking the required physician's signature. The resident, an elderly female with diagnoses including Type 1 Diabetes Mellitus, muscle wasting and atrophy, and dehydration, was admitted with a documented DNR status on her electronic face sheet, care plan, and physician orders. However, review of the OOH-DNR form revealed it was undated and missing the attending physician's signature in the designated sections, which is necessary to make the document official and legally binding. Interviews with facility staff, including the ADON, Social Services, and DON, confirmed that while the DNR status was discussed and documented in the electronic record, the OOH-DNR form was not fully executed as required. The Social Services staff member, responsible for completing the form, acknowledged that the physician's signature is essential for the document's validity. The DON stated that a verbal order from the physician was obtained and used to update the code status, but the OOH-DNR form itself remained incomplete without the physician's signature. Facility policy requires the physician's signature on the OOH-DNR form to implement advance directives, which was not followed in this instance.
Failure to Label IV Dressing According to Facility Policy
Penalty
Summary
A deficiency occurred when a resident with a history of Type 1 Diabetes Mellitus, muscle wasting, atrophy, and dehydration was found to have a peripheral intravenous (IV) lock covered with a transparent dressing that was not dated or initialed. The resident's care plan required frequent monitoring of the IV site for signs of infection or infiltration, and the facility's policy specified that the dressing should be labeled appropriately. During observation, the dressing on the resident's right hand lacked both a date and initials, and interviews with nursing staff and the DON confirmed that the nurse who inserted the IV was responsible for labeling the dressing. The staff acknowledged the importance of labeling to track when the IV was placed or last changed. Record review and staff interviews revealed that the facility's policy and standard nursing practice require IV dressings to be dated and initialed to ensure timely changes and proper monitoring. The DON and nursing staff were unable to determine who had placed the IV due to missing documentation, and the nurse assigned to the resident could not recall recent training on IV administration. The failure to label the IV dressing was directly observed and confirmed by staff, and the facility's own policy outlined the requirement for proper labeling of IV dressings.
Improper Storage of Medication at Bedside
Penalty
Summary
A deficiency occurred when a normal saline flush, classified as a drug/biological, was found stored at the bedside of a resident rather than in a locked compartment as required. The resident, a female with diagnoses including type 1 diabetes mellitus, muscle wasting, atrophy, and dehydration, was severely cognitively impaired according to her BIMS score. Her care plan included monitoring for complications related to intravenous therapy. During an observation, the normal saline flush was seen on the resident's television stand, and the resident stated that a nurse had left it there. Interviews with facility staff, including an LVN and the DON, confirmed that medications or saline flushes should not be left at the bedside, as this could allow access by residents or visitors and risk contamination or adverse reactions. Review of facility policy also indicated that medication storage should be secure and locked when not in use. The failure to store the normal saline flush in a locked compartment constituted noncompliance with professional standards and facility policy.
Improper Perineal and Catheter Care Technique Observed
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate perineal and catheter care to a male resident with an indwelling Foley catheter. The resident, who had a history of hematuria, benign prostatic hyperplasia, urinary retention, and urinary tract infection, was observed during care where the CNA reused wipes multiple times when cleaning the urethral opening of the penis. The CNA also provided incontinence care with the resident standing, despite the resident expressing discomfort and fatigue during the process. The resident's catheter tubing was observed to be hanging due to gravity during the care. Interviews revealed inconsistencies in staff training and understanding of proper catheter care techniques. The CNA involved stated she had been trained to use a new wipe for each swipe but did not recall reusing wipes during the observed care, acknowledging that reusing wipes could lead to contamination and infection. The Director of Nursing (DON) and another CNA responsible for training provided conflicting information regarding the correct procedure, with the trainer emphasizing the importance of using one wipe per swipe and performing care with the resident lying down for better access and visibility. A review of facility policies and training materials showed that while the facility conducted regular training and competency checks, the written policy did not clearly define the clean technique or specify the use of wipes versus washcloths. The Texas nurse aide curriculum referenced by the facility also lacked specific guidance on the use of wipes. The observed deficient practice of reusing wipes and providing care with the resident standing was not aligned with the training described by the staff and could contribute to infection risk.
Failure to Include Pruritus and Itching Behaviors in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed all identified needs for a resident, specifically omitting the resident's pruritus (itchy skin) and associated behaviors of itching and scratching from the care plan. The resident, a male with multiple diagnoses including type 2 diabetes mellitus, bladder cancer, acute respiratory failure, dysphagia, and nontraumatic intracranial hemorrhage, was cognitively intact and had expressed concerns about itching during a care plan meeting. Documentation showed that medical staff were aware of the pruritus, a dermatology referral was made, and topical treatments were used, which improved the resident's symptoms. Despite these interventions and ongoing awareness among nursing staff, the resident's care plan did not include any specific mention of pruritus or the behaviors of itching and scratching. Both the Treatment Nurse and the MDS nurse acknowledged during interviews that these conditions and behaviors should have been included in the care plan. The care plan only contained general statements about skin assessment and risk for skin breakdown, without addressing the specific issue of pruritus or the resident's behaviors. The staff could not provide a clear reason for this omission, even though they recognized the importance of accurately reflecting all current conditions and behaviors in the care plan. Facility policy required that care plans be reflective of identified problems or risks, include measurable outcome objectives, and appropriate interventions. The DON, MDS nurse, and Treatment Nurse all confirmed that skin conditions and related behaviors should be documented in the care plan if present. However, the care plan for this resident was not updated to include pruritus or the associated behaviors, despite ongoing documentation and staff awareness of the issue. This failure was identified through record review and staff interviews.
Failure to Document Weekly Physician-Ordered Skin Assessment
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident by not documenting a physician-ordered weekly total body skin assessment. The resident, a cognitively intact male with multiple diagnoses including type 2 diabetes mellitus, bladder cancer, acute respiratory failure, dysphagia, and nontraumatic intracranial hemorrhage, had an active order for weekly skin assessments every Monday. Record review showed that the last documented skin assessment was completed on 02/19/25, with no documentation for the following week as required by the physician's order. Interviews with the Treatment Nurse revealed that she was responsible for completing weekly skin assessments but was not working from 02/13/25 to 03/03/25. During her absence, the DON was expected to delegate or complete the assessments. The Treatment Nurse was unable to identify who, if anyone, completed the assessment for the week of 02/26/25 and confirmed that the last documented assessment was on 02/19/25. She acknowledged the importance of following physician orders and documenting assessments but was unsure of the facility's policy and had not received specific training on documentation procedures. The DON confirmed responsibility for completing the skin assessments during the Treatment Nurse's absence and stated that she completed the assessment on 02/26/25 but did not document it in the resident's record, attributing the omission to oversight. The DON also confirmed the importance of documentation and stated that the facility policy required weekly skin assessments to be documented in the medical record. Review of competency checklists indicated that both the DON and Treatment Nurse had been checked off as competent in skin assessment and documentation. Facility policy also specified that weekly skin assessments should be documented by a licensed nurse.
Inaccurate Documentation of Neuro Checks Post-Fall
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically in the documentation of neuro checks following a fall. The resident, a female with a history of end-stage renal failure, muscle weakness, and fractures, experienced a fall from her bed while reaching for snacks. Although the resident was found alert and oriented with no visible injuries, neuro checks were initiated as per facility protocol. The neuro checks, which were supposed to be conducted at specific intervals, were not accurately documented by four nurses. The records showed repeated vital signs entries with the same readings and dates, indicating that new vital signs were not recorded as required. Interviews with the involved nurses revealed that they had conducted the checks and noted the vitals on paper but failed to transfer the updated information to the electronic medical record. This resulted in the documentation showing incorrect and outdated vital signs. The Director of Nursing (DON) confirmed the discrepancies in the neuro check documentation and acknowledged that the nursing staff did not follow the protocol of recording new vital signs at each interval. Despite the documentation errors, the DON noted that there were no negative effects on the resident, as she had not sustained any injuries from the fall. The facility's policy on professional standards of care emphasizes the importance of accurate documentation, which was not adhered to in this case.
Failure to Include Oxygen Treatment in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included the omission of oxygen treatment in the care plan. This deficiency was identified during a review of the resident's records, which showed no physician's order for oxygen, despite the resident using oxygen via nasal cannula daily. The resident, a male with a history of pneumonia, encephalopathy, transient ischemic attack, cerebral infarction, chronic kidney disease stage 3, and major depressive disorder, was observed using oxygen without a corresponding care plan. Interviews with facility staff revealed that the MDS coordinator was responsible for care planning and had not received a physician's order for the oxygen, leading to its exclusion from the care plan. The Director of Nursing acknowledged that the absence of a care plan for oxygen could result in staff not being aware of the resident's needs, potentially leading to inadequate oxygen support. The facility's policy requires that care plans include measurable objectives and interventions for identified needs, which was not adhered to in this case.
Deficiencies in Oxygen Therapy Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen therapy management. Resident #187, a male with severe cognitive impairment and multiple health conditions, was observed using oxygen via a nasal cannula without a physician's order or an oxygen sign posted on his door. Interviews with staff revealed that the responsibility for posting oxygen signs and ensuring physician orders were in place was not adequately managed, as the nurse assumed the order was already in place. Similarly, Resident #78, a female with severe cognitive impairment and a history of strokes and heart failure, was also receiving oxygen therapy without a physician's order. Observations confirmed the use of oxygen via nasal cannula, but the necessary physician's order was missing from her records. Staff interviews indicated a lack of clarity on who was responsible for entering physician orders into the electronic record, leading to the oversight. The facility's policies on oxygen administration require a physician's order for oxygen therapy, but these were not followed for the two residents. The absence of physician orders and proper signage for oxygen use could lead to potential risks, as noted by the staff, but the report does not detail any specific consequences that occurred as a result of these deficiencies.
Failure to Label and Date Food Items in Freezer
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not ensure that all food items in the freezer were labeled and dated, which is a requirement according to their policy. An open bag containing five slices of French toast was found in the freezer without any labeling or dating, exposing it to air. During an interview, a staff member admitted to not knowing how long the French toast had been in the freezer and acknowledged the importance of labeling and dating food items to prevent contamination and ensure quality. The staff member also mentioned that they could not recall the last time they received training on this procedure. The Dietary Manager confirmed that all dietary employees are aware of the requirement to label and date food items in storage areas, as per the facility's policy, which aligns with state, federal, and US Food Codes and HACCP guidelines.
Infection Control Lapses in PPE Use and Visitor Notification
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) did not adhere to Enhanced Barrier Precautions (EBP) while administering medication via a G-tube to a resident. Despite the presence of an EBP sign and available personal protective equipment (PPE) outside the resident's room, the LVN only wore gloves and not a gown, as required. The LVN admitted to forgetting to wear the gown due to nervousness, acknowledging that the resident was on EBP due to having a G-tube, which necessitates gown and glove use to prevent infection spread. In the second incident, the facility failed to inform visitors that another resident was on contact precautions due to an infection with ESBL in the urine. There was no contact precaution sign posted on the resident's door, and a visitor reported not being informed about the contagious nature of the infection, nor using PPE during visits. The LVN confirmed the resident's contact precaution status and acknowledged the importance of informing visitors and placing signs to prevent infection spread. The Director of Nursing (DON) confirmed that visitors should have been informed and required to wear PPE, and that signs should have been posted to alert staff and visitors. The facility's policy on infection prevention and control, which includes the use of EBP and contact precautions, was not followed in these instances. The policy outlines the necessity of using PPE during high-contact activities and ensuring that signs are posted to inform and protect staff and visitors. These lapses in protocol could lead to cross-contamination and the spread of infections among residents and visitors.
Neglect During Foley Catheter Change
Penalty
Summary
The facility failed to protect a resident from neglect during a Foley catheter change, which resulted in the resident experiencing significant discomfort and pain. The resident, a male with severe cognitive impairment and multiple medical conditions including urinary tract infection and benign prostatic hyperplasia, was subjected to a catheter change by LVN D and LVN R. Despite the resident's cries of pain and requests to stop, the nurses continued the procedure, which is against the protocol that requires stopping if a resident expresses discomfort. During the procedure, the resident cried out and expressed significant distress, yet the nurses did not cease the procedure immediately. LVN D and LVN R failed to recognize and appropriately respond to the resident's pain, which was evident in a video recording of the incident. The resident's cries for help were ignored, and the catheter change was completed despite the resident's clear indications of pain and discomfort. The incident was further compounded by the lack of immediate and appropriate response from the nursing staff, as they did not stop the procedure or provide any pain relief measures. The situation escalated to the point where the resident was transferred to the hospital due to hematuria, which was noted after the catheter change. This neglectful action placed the resident at risk of further harm and highlighted a significant deficiency in the facility's care practices.
Failure to Implement Abuse Prevention Policies During Catheter Change
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of a male resident with severe cognitive impairment. The resident, who had a history of urinary tract infection, hematuria, benign prostatic hyperplasia, dementia, and heart failure, experienced pain during a Foley catheter change. Despite the resident's cries of pain and requests to stop, the licensed vocational nurses (LVNs) involved did not cease the procedure, which resulted in the resident being hospitalized due to hematuria. The incident occurred when LVN D and LVN R were changing the resident's Foley catheter. The resident expressed discomfort and pain, yet the nurses continued with the procedure. LVN D initially attempted to advance the catheter but encountered resistance. Despite this, the procedure continued, and the resident was not medicated for pain before or after the catheter change. The resident's cries for help were ignored, and the situation was not reported to the facility's administrator as required by the facility's abuse policy. The failure to adhere to the facility's Abuse Neglect Exploitation (ANE) policy and the lack of appropriate response to the resident's pain and distress led to the identification of Immediate Jeopardy. The facility's staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), were aware of the situation but did not take immediate corrective action. The resident was eventually sent to the hospital after continued bleeding was observed in the catheter bag, highlighting the severity of the oversight and the potential risk to other residents.
Removal Plan
- The resident identified as #2 was reassessed and Resident #2's plan of care reviewed to validate that appropriate intervention is in place related to foley insertion and care.
- Regional Nurse / Director of Nursing provided in-service training to LVN D, LVN R, and RN ADON regarding Abuse Neglect and Exploitation Prevention, Reporting and Protecting, and Procedure for insertion of indwelling foley catheter.
- Monitoring, assessing for signs/symptoms of pain prior to procedure, during procedure and responding to any complaints of pain; including stopping the procedure, providing non-pharmacological and pharmacological interventions to relieve discomfort.
- If resistance is noted upon insertion of the indwelling foley catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, and notify the PCP for further instructions.
- Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP.
- Director of Nursing / Assistant Director of Nursing / Designee conducted an audit to identify all residents with indwelling foley catheters to identify any resident having signs/symptoms of pain associated with the catheter and/or signs/symptoms of hematuria.
- Director of Nursing / Assistant Director of Nursing / Designee interviewed residents with indwelling foley catheters to identify any concerns of pain during the procedure of changing of catheter.
- The Regional Nurse / DNS educated the licensed nurses regarding Abuse Neglect and Exploitation Prevention, Reporting and Protecting, and Procedure for insertion of indwelling foley catheter.
- Director of Nursing / Assistant Director of Nursing and Clinical Leadership will conduct training for all newly hired nurses, PRN nurses and agency nurses prior to the nurses working.
- Director of Nursing / Assistant Director of Nursing will require nurses to perform return demonstration of the procedure for the insertion of the foley catheter to establish competency.
- The Administrator and Director of Nurses conducted an Ad Hoc QAPI review of this situation and the immediate corrective action plan with the facility's Medical Director.
- Director of Nursing / Assistant Director of Nursing / Designee will conduct audits/rounds to inspect residents with indwelling foley catheters to identify signs/symptoms of hematuria and observe nurses during the procedure of placing/changing an indwelling catheter to evaluate competency.
- Director of Nursing / Assistant Director of Nursing / Designee will review the nursing 24hr report, and progress notes to identify issues with placing/changing the indwelling foley catheter and ensure appropriate follow-up interventions are in place.
- All findings will be reported to the QAPI committee and the committee will determine compliance or additional training and oversight is required.
Resident Elopes Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment for a resident with severe cognitive impairment and a history of wandering and exit-seeking behavior. The resident, who had been admitted for rehabilitation services, was able to exit the facility undetected and was found in the parking lot, close to a busy two-way street. Despite previous observations and documentation of the resident's wandering tendencies, the care plan did not adequately address these behaviors prior to the incident. Interviews with staff revealed that the resident had been observed attempting to exit the facility on multiple occasions, yet the care plan to manage these behaviors was not implemented until after the incident. The resident's exit-seeking behavior had been discussed in care plan meetings, but the necessary interventions were not put in place in a timely manner. The facility lacked wander guards, and although emergency exits were alarmed, the front doors through which the resident exited were not adequately monitored. The incident was not reported to the state, as the facility's administration believed it did not meet the criteria for reporting. The facility's Director of Nursing and Administrator acknowledged the resident's wandering behavior but did not activate a code yellow, as the resident was not considered missing. The lack of immediate and effective response to the resident's exit-seeking behavior highlights a significant oversight in the facility's supervision and safety protocols.
Failure to Provide Appropriate Catheter Care Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a urinary catheter, leading to an Immediate Jeopardy situation. During a Foley catheter change for a male resident with a history of urinary tract infections, hematuria, benign prostatic hyperplasia, dementia, and heart failure, the licensed vocational nurses (LVNs) involved did not stop the procedure when resistance was felt. Despite the resident's cries of pain and requests to stop, the LVNs continued with the catheter change without notifying the doctor or taking appropriate action to address the resident's discomfort. The resident, who had severely impaired cognition and was bedbound, experienced hematuria and pain following the catheter change. The LVNs involved in the procedure failed to recognize and respond to the resident's distress, as evidenced by a video recording where the resident was heard yelling and pleading for the procedure to stop. The LVNs did not acknowledge the resident's pain or discomfort during interviews, despite the video evidence showing otherwise. The facility's failure to stop the procedure and notify the physician when resistance was encountered during the catheter change resulted in the resident being sent to the hospital for further evaluation. The Immediate Jeopardy was identified due to the potential for more than minimal harm to residents receiving Foley catheter changes, as the facility did not ensure that staff were adequately trained to handle such situations appropriately.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an incident involving a resident who exited the facility unsupervised, which was a violation of the requirement to report alleged neglect to the State Survey Agency within 24 hours. The incident occurred when a resident with severe cognitive impairment and a history of wandering behavior exited the facility through the front door and was found in the parking lot. Despite the resident being quickly redirected back into the facility without injury, the incident was not reported to the state as required. The resident involved was an elderly female with diagnoses including dementia, muscle weakness, and malnutrition. Her quarterly MDS indicated a severely impaired cognitive status with wandering behavior occurring frequently. The care plan had identified her as exit-seeking and at risk for elopement, with interventions in place such as 1:1 supervision and distraction techniques. However, on the day of the incident, the resident managed to leave the facility, reaching the far end of the parking lot near a busy street before being escorted back inside. Interviews with staff revealed that the resident was not immediately noticed missing until seen by CNAs through a window. The facility's Director of Nursing (DON) and Administrator both acknowledged the incident but did not report it, believing it was unnecessary since the resident was found quickly and did not leave the premises. The facility's policy required reporting of such incidents, but the Administrator cited corporate guidelines as the reason for not reporting. The lack of timely reporting could increase the risk of unreported allegations of neglect, potentially affecting all residents.
Failure to Update Care Plan for Resident with Wandering Behaviors
Penalty
Summary
The facility failed to ensure that the care plan for a resident with dementia, muscle weakness, and malnutrition was reviewed and revised by the interdisciplinary team after each assessment. The resident, who was severely cognitively impaired, exhibited wandering and exit-seeking behaviors that were not addressed in the care plan until March 27, 2024, despite these behaviors being observed and documented in progress notes as early as January 2024. The care plan was not updated to include interventions for these behaviors until several months after they were first noted. Interviews with staff revealed that the resident's wandering and exit-seeking behaviors were known to the staff, and attempts were made to redirect the resident when she was found trying to exit the facility. The social worker and other staff members had communicated with the resident's responsible party about these behaviors and the potential need for a memory care unit. However, the care plan was not updated in a timely manner to reflect these discussions and the resident's needs. The facility's policies required that care plans be updated and reviewed at least quarterly and with significant changes in conditions. Despite this, the resident's care plan did not include her wandering and exit-seeking behaviors until March 2024, which was a significant oversight given the documented instances of these behaviors. The facility's failure to update the care plan in a timely manner could have resulted in missed or delayed continuity of care for the resident.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically by not ensuring the availability of the physician-ordered medication Entresto for heart failure. The resident, a male with multiple serious health conditions including hypertension, chronic kidney disease, and heart disease, was admitted to the facility and had an order for Entresto to be administered twice daily. However, the medication was not available on the day it was needed, and the resident did not receive his prescribed dose on that day. The report details that the medication was not in the facility's Pyxis system, and the pharmacy used by the facility would not have been able to deliver the medication until the following evening. Despite being informed of the unavailability of the medication, the responsible nurse did not notify the doctor or the pharmacy to seek an alternative solution. The nurse and the Certified Medication Aide (CMA) both acknowledged that they were aware of the protocol to notify the doctor and pharmacy when medications were not available, but this protocol was not followed. Interviews with the Director of Nursing (DON) and other staff revealed that there was a lack of documentation and verification regarding the availability of Entresto upon the resident's admission. The DON admitted that the facility's policy required timely acquisition and administration of medications, and that the failure to notify the doctor about the unavailability of Entresto could negatively impact the resident. Despite training provided to staff on the importance of making such notifications, the necessary steps were not taken in this instance, leading to the deficiency noted in the report.
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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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