Misty Willow Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 12921 Misty Willow Dr, Houston, Texas 77070
- CMS Provider Number
- 676251
- Inspections on file
- 26
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 16 (5 serious)
Citation history
Health deficiencies cited at Misty Willow Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact resident with stroke-related hemiplegia, morbid obesity, and high fall risk required extensive assistance for transfers. During an assisted wheelchair-to-bed transfer by two CNAs, the resident slipped, was lowered to the floor, reported hearing a crack in her leg, and described crying out in pain as staff struggled to get her up, with her leg becoming caught under equipment. No nurse assessed her at the time, no fall was documented in the record, and the DON, MD, and family were not notified when the event occurred. Over the next days, the resident experienced significant pain and later swelling and severe leg pain before being sent to the hospital, where a left femur fracture was diagnosed. Surveyors found the facility failed to assess the resident after the fall and failed for several days to seek medical guidance or report a fall that resulted in pain, swelling, and a broken femur, constituting noncompliance with professional standards of practice and the resident’s care plan.
A resident with a history of stroke, hemiplegia, and significant mobility limitations experienced an assisted fall during a wheelchair-to-bed transfer performed by two CNAs, during which her leg slipped forward and she was lowered to the floor. The resident reported hearing a crack, crying on the floor, and later having severe pain and difficulty sleeping, while her roommate observed her curled up in bed, crying and complaining of a painful fall. Despite facility policy that all falls be reported to the DON, the fall was not promptly reported or fully assessed; staff accounts conflicted about whether an LVN had been notified and whether a head-to-toe assessment was attempted. Over the next days, the resident’s documented pain scores increased, and only after severe pain and visible swelling were noted by nursing leadership was she sent to the hospital, where a left femur fracture was diagnosed, and her family was informed of the fall. This sequence reflects a failure to follow fall protocols, ensure timely nursing assessment, and uphold the resident’s right to dignified care and communication.
A male resident with severe cognitive impairment and a history of sexually inappropriate behaviors repeatedly touched female residents inappropriately, including incidents in hallways, the dining room, and resident rooms. Despite staff awareness and documentation of these behaviors, the facility did not implement effective supervision or interventions to prevent further abuse, resulting in multiple incidents involving vulnerable residents with cognitive impairments.
A male resident with severe cognitive impairment and a history of sexually inappropriate behaviors repeatedly inappropriately touched two female residents with severe cognitive impairment. Staff were not consistently informed or trained on the resident's behaviors or required interventions, and incidents were not always reported immediately to the Administrator. Care plans were not promptly updated, and supervision measures were inconsistently applied, resulting in repeated incidents of sexual abuse.
A male resident with a history of sexually inappropriate behaviors was involved in multiple incidents of sexual abuse against two female residents with severe cognitive impairment. Despite repeated incidents, the facility did not consistently update care plans, inform staff of necessary interventions, or provide adequate supervision, resulting in ongoing risk of abuse and lack of thorough investigation.
A resident with severe cognitive impairment and a history of sexually inappropriate behaviors repeatedly touched other residents inappropriately over several months. The care plan was not adequately updated after each incident, and staff, including LVNs and CNAs, were not consistently informed or trained on interventions to prevent further occurrences. This lack of timely care plan revision and insufficient staff awareness resulted in ongoing risk to other residents.
A resident with dementia and depression was not informed by facility staff of a visitation restriction placed on her family member due to safety concerns involving staff. The facility did not document or communicate the restriction to the resident, instead relying on another family member to relay the information, and did not follow its own policy requiring notification of visitation rights and restrictions.
A resident with severe cognitive impairment and total dependence for care was found on the floor by her roommate, displaying signs of injury including head bleeding and hip pain. Staff failed to immediately assess her condition, did not administer ordered PRN pain medication, and moved her from the floor to the bed before calling 911, contrary to care plan and physician orders. The resident sustained a hip fracture and head injury, and was left unsupervised with her roommate after the incident.
A resident with severe cognitive impairment and hemiplegia was found on the floor after a fall and complained of hip pain. Staff lifted the resident from the floor to the bed without following proper assessment and transfer protocols, resulting in multiple injuries including a head laceration and femur fracture. Staff interviews revealed inconsistent understanding and application of fall and transfer procedures, and the transfer was not performed according to facility policy.
Two residents did not receive medications as ordered due to failures in medication administration and communication. One resident was given aspirin without a physician's order following a head injury, and another did not receive prescribed IV antibiotics for a UTI due to miscommunication between the facility and dialysis center, as well as incomplete follow-up and documentation by staff.
The facility failed to maintain proper infection control practices, as a CNA did not follow hand hygiene protocols during incontinence care for a resident, and a wound care nurse neglected hand hygiene before and after assessing a resident's heels. Both staff members acknowledged the importance of hand hygiene but did not adhere to the facility's policy.
A resident with dementia and other medical conditions was not afforded privacy during Foley catheter care, as CNAs failed to close the blinds, compromising the resident's dignity. The facility's policy and care plan emphasized the importance of privacy, which was not adhered to during this incident.
A resident with multiple health issues, including dementia and diabetes, developed a pressure ulcer on the right heel due to the facility's failure to offload the heels as per the care plan. Despite having heel protectors available, staff did not use them, and the resident's heels were not offloaded during care, leading to an unstageable pressure wound. Interviews confirmed that it was the responsibility of both nursing staff and CNAs to prevent such injuries, as per facility policy.
A resident with a history of urinary tract infections and other health issues did not receive proper incontinence care, as a CNA failed to follow the facility's perineal care policy. This included not opening the labia to clean and not wiping around the buttocks, which was confirmed by the DON as a risk for infections.
A resident requiring continuous oxygen therapy had an unlabeled oxygen humidifier, contrary to facility policy. The resident, with chronic obstructive pulmonary disease and other conditions, was observed with the unlabeled equipment. An LVN admitted responsibility for ensuring proper labeling, which should be checked every shift. The facility's policy requires humidifiers to be dated and replaced every ten days.
The facility failed to properly label medications, including eye drops and nasal sprays, on medication carts and in the medication room. Observations revealed that several medications were opened but not labeled with resident names or dates, contrary to facility policy. The DON confirmed that all medications must have pharmacy labels with open dates to ensure effectiveness, and improperly labeled medications must be discarded.
Failure to Assess and Report Assisted Fall Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively intact resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices following an assisted fall. The resident was an older female with multiple significant diagnoses, including hypertension, type 2 diabetes, anemia, stroke with left-sided hemiplegia/hemiparesis, cognitive communication deficit, muscle weakness, morbid obesity, and high fall risk. Her MDS showed she required substantial to total assistance for bed mobility and transfers, including dependence on staff for sit-to-stand and bed-to-chair transfers. Her care plan identified her as at risk for falls related to weakness and hemiplegia and documented the need for assistance with ADLs and transfers. According to interviews and record review, the resident reported that on an evening after dinner she fell during a transfer from wheelchair to bed when two CNAs attempted to assist her. She stated her leg slipped forward, she heard a crack, and the CNAs lowered her to the floor. While on the floor, she reported hollering and crying in pain as the CNAs tried to get her up, during which her leg became caught under the wheelchair and then under the bed. She stated no nurse was called to assess her, and no nurse came to evaluate her for pain or injury at that time. A roommate later reported seeing the resident in bed crying and curled up, saying she had a nasty fall and was in pain, and that the resident continued whining and whimpering for hours. Facility documentation showed no fall entry in the progress notes between the dates surrounding the alleged event, and the incident report later created reflected only that the resident was alert in bed alleging a fall a few days prior, with no specific date and no witnesses. The DON stated she was not notified of the fall when it occurred, despite facility protocol requiring the DON to be called for all falls, and that she only learned of the event days later when the resident complained of pain and swelling in the left leg. The DON’s investigation found that two CNAs had assisted the transfer when the resident slipped to the floor and that they claimed to have reported the fall to a nurse, while the LVN on duty denied being informed of any fall. During the period after the fall and before hospital transfer, documentation showed administration of PRN acetaminophen for pain, but there was no contemporaneous nursing assessment or documentation of a fall, and the family was not informed of the fall until the resident was sent to the hospital, where she was diagnosed with a left femur fracture. The facility’s failure included not promptly assessing the resident after the assisted fall, not documenting the fall in the medical record at the time it occurred, not notifying the DON, physician, or family when the fall happened, and not seeking timely medical guidance despite the resident’s subsequent complaints of pain and later-observed swelling and severe leg pain. The surveyors determined that the facility failed to seek medical guidance or report a fall that resulted in injury, including pain, swelling, and a broken femur, for approximately three days, and that the nurse failed to assess the resident after the fall. These failures were cited as noncompliance with the requirement to provide treatment and care in accordance with professional standards of practice and the resident’s comprehensive assessment and care plan. The report also notes that this deficient practice was identified as Immediate Jeopardy to resident health and safety at a specific time and date, based on the delay in appropriate medical evaluation and treatment following the fall and resulting fracture. The Immediate Jeopardy was later removed, but the facility remained out of compliance at a lower scope and severity while it continued to monitor implementation and effectiveness of its corrective actions. The failures were described as placing residents at risk for delay of appropriate medical treatment leading to pain, discomfort, and death.
Failure to Follow Fall Protocols and Provide Timely Assessment After Assisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to treat a cognitively intact resident with respect and dignity and to follow fall protocols, including timely nursing assessment and reporting, after an assisted fall. The resident was an older female with a history of stroke resulting in hemiplegia/hemiparesis on the left side, muscle weakness, lack of coordination, morbid obesity, and other neurologic and functional impairments. Her discharge MDS showed a BIMS score of 13/15, indicating she was cognitively intact, and she required extensive assistance for bed mobility and transfers, with helpers doing all the effort or requiring two or more helpers. Her care plan identified her as at risk for falls related to weakness and hemiplegia/hemiparesis. According to the complaint and interviews, the resident experienced an assisted fall during a wheelchair-to-bed transfer performed by two CNAs. One CNA reported that during the transfer the resident began to slip, her leg slipped forward, and she was slowly lowered to the floor. The resident stated she heard a crack, was lowered to the floor, cried while on the floor, and that the CNAs struggled to get her back into bed. She reported significant pain that night, difficulty sleeping, and emotional distress as she replayed the fall in her mind. Her roommate later observed her curled up in bed, crying and whimpering, and reported that the resident said she had a “nasty fall” and was in pain. The roommate stated the resident continued to whine and whimper in bed for hours. The facility did not ensure that the fall was promptly assessed and reported according to protocol. The DON stated that all falls were to be reported to her, but she was not notified until days later, after the resident complained of leg pain. There were conflicting accounts among staff: the CNAs stated they reported the fall to an LVN, while the LVN initially stated she had not been made aware of the fall, then later stated she was contacted by the ADON about a reported fall and was instructed to perform a head-to-toe assessment, which she said the resident refused. The resident’s pain assessments on the MAR showed varying pain scores over the days following the fall, culminating in a severe pain score, and only then was she assessed by nursing leadership, found to have pain and swelling in the left leg, and sent to the hospital where a left femur fracture was diagnosed. The family was not informed of the fall until the day of transfer to the hospital. These actions and inactions demonstrate that the facility did not follow its fall protocols, did not ensure timely nursing assessment after the fall, and did not uphold the resident’s right to dignified care and communication about her condition.
Failure to Prevent Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, resulting in multiple incidents involving a male resident who inappropriately touched female residents on several occasions. The male resident, who had severe cognitive impairment and a history of sexually inappropriate behaviors, was observed by staff touching the breasts and thighs of female residents, some of whom also had severe cognitive impairment and were unable to advocate for themselves. These incidents occurred in various locations within the facility, including hallways, the dining room, and resident rooms, and were witnessed by CNAs and reported to nursing staff. Despite the initial incident of sexual abuse, the facility did not implement effective measures to prevent further occurrences. The male resident continued to have access to vulnerable female residents, and additional incidents of inappropriate touching were documented over several months. Staff interviews revealed that the male resident would sometimes offer snacks to other residents as a means of interaction, and that supervision and monitoring were inconsistent. Care plans for the involved residents noted their cognitive impairments and wandering behaviors, but interventions to prevent abuse were not adequately enforced or updated in a timely manner following each incident. Documentation and interviews indicated that staff were aware of the male resident's behaviors and the risks posed to other residents, yet failed to consistently separate him from potential victims or provide sufficient supervision. The facility's policies required protection from abuse, but these were not effectively implemented, resulting in repeated incidents. The failures placed residents at risk of abuse, mental anguish, and fearfulness, as confirmed by the survey findings.
Failure to Prevent and Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement and enforce written policies and procedures to prohibit and prevent abuse, specifically sexual abuse, among residents. Over a four-month period, a male resident with severe cognitive impairment and a history of sexually inappropriate behaviors inappropriately touched at least two female residents, both of whom also had severe cognitive impairment and were unable to advocate for themselves. Despite documented incidents of inappropriate touching, including fondling of breasts and inner thighs, the facility did not consistently update care plans, provide adequate supervision, or ensure staff were informed of the resident's behaviors and necessary interventions. Staff members, including LVNs and CNAs, were not consistently aware of the male resident's history of sexual behaviors or the interventions required to prevent further incidents. Several staff interviews revealed a lack of specific training or in-service education regarding the resident's behaviors and the facility's abuse prevention protocols. In some cases, staff did not immediately report incidents of abuse to the Administrator as required by policy, and there was confusion about the appropriate steps to take following such incidents. The care plans for the involved residents were not always updated promptly to reflect new risks or interventions after incidents occurred. The facility's failure to separate residents after incidents, provide 1:1 supervision when indicated, and ensure all staff were aware of and trained on abuse prevention measures contributed to repeated occurrences of sexual abuse. The male resident continued to have access to vulnerable female residents, and interventions such as increased supervision or room changes were inconsistently applied. These failures placed residents at risk of further abuse, mental anguish, and fearfulness, as documented by surveyor observations, interviews, and record reviews.
Removal Plan
- Facility Medical Director was notified of the Immediate Jeopardy (IJ) by the Administrator.
- Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made.
- The ED/ DON/ Social Worker and RN, Clinical Resource will be trained on Abuse/ Neglect Investigation and Reporting by Risk Management Resource, including how to conduct a thorough investigation to implement measures to prevent further incidents and protect other residents.
- Training and knowledge checks (Post-Test) were initiated with all staff on shift regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s). This training was given by RN, Clinical Resource. Training & Knowledge Check including Post-Test will be completed with all staff. Any remaining staff member(s) pending Training & Knowledge check will complete the Training & Knowledge Check including Post-Test prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks.
- Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan.
- This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.
- DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s)) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter. This audit was completed and no additional discrepancies were identified.
- Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents.
- Safe-Surveys were conducted by Licensed Social Worker, with no additional or similar concerns about individual safety verbalized by Interviewed resident(s). Interviewable resident(s) were included in the Safe-Surveys. The Safe-Survey Questionnaire entails facility staff providing care with dignity & respect, any form of Abuse either by Staff or resident, patient safety & who is the Abuse Coordinator for facility to report.
Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate all alleged violations of sexual abuse and did not take adequate steps to prevent further potential abuse for two residents with severe cognitive impairment. Over a four-month period, a male resident with a history of sexually inappropriate behaviors was involved in multiple incidents of sexual abuse against two female residents and an unidentified female resident. Despite documented incidents where the male resident was observed touching female residents inappropriately, the facility did not consistently implement or update interventions to prevent recurrence, nor did they ensure that all staff were informed of the resident's behaviors and the necessary supervision measures. Record reviews and staff interviews revealed that the male resident had a documented history of sexually inappropriate behaviors, including touching female residents' breasts and inner thighs. Staff members reported that they were not always informed of the resident's history or the interventions required to prevent further incidents. In several cases, staff intervened only after witnessing inappropriate behavior, and there was a lack of evidence that care plans were updated or that supervision was consistently provided following each incident. Additionally, some incidents were not reported or investigated according to the facility's abuse prevention policy, and staff training on specific interventions for the resident was lacking. The affected female residents had severe cognitive impairment and were unable to advocate for themselves or recall the incidents. The facility's failure to thoroughly investigate all allegations, update care plans, and ensure staff were adequately trained and informed resulted in repeated incidents of sexual abuse. The lack of consistent supervision and failure to implement protective measures placed residents at risk of further abuse, mental anguish, and fearfulness.
Removal Plan
- Facility Medical Director was notified of the Immediate Jeopardy (IJ) by the Administrator.
- Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made.
- Training and knowledge checks (Post-Test) were initiated with all staff on shift regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s).
- Training & Knowledge Check including Post-Test will be completed with all staff. Any remaining staff member(s) pending Training and knowledge check will complete the Training and Knowledge Check prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks.
- Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan, as additional intervention tool to ensure timely interventions/investigation(s) are implemented.
- DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s)) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter. No additional discrepancies were identified.
- Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents.
- This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.
- DON/ designee/ Cluster Partners will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated appropriately.
- DON/ Designee will review the 24-[NAME]
Failure to Update and Implement Comprehensive Care Plan for Resident with Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address the nursing, mental, and psychosocial needs of a resident who exhibited sexually inappropriate behaviors. Despite multiple incidents of the resident inappropriately touching other residents over a four-month period, the care plan was not revised in a timely or adequate manner to reflect new interventions or increased supervision. Nursing staff, including LVNs and CNAs, were not consistently aware of or trained on specific interventions to prevent further incidents, and several staff members reported not being informed of the resident's behaviors or the necessary preventive measures. The resident in question had a history of severe cognitive impairment, mild depression, and diagnoses including dementia and adjustment disorder with anxiety. Multiple documented incidents occurred in which the resident touched female residents inappropriately, often targeting those with poor cognition who could not advocate for themselves. Staff responses to these incidents varied, with some staff intervening immediately and others unaware of the resident's behavioral history or required interventions. The care plan was only sporadically updated, and interventions such as 1:1 supervision were inconsistently implemented or communicated among staff. Interviews with staff revealed gaps in communication, training, and care plan updates following each incident. Some staff were unaware of the resident's behavioral risks until after witnessing an incident, and others did not review the care plan or receive specific in-services related to the resident's behaviors. The lack of a coordinated, updated care plan and insufficient staff awareness placed other residents at risk of not having their behavioral needs met, potentially leading to further abuse and emotional distress.
Failure to Inform Resident of Visitation Rights and Restrictions
Penalty
Summary
The facility failed to inform a resident of her visitation rights and the related facility policy and procedures, including any safety restrictions or limitations, the reasons for such restrictions, and to whom the restrictions applied. This deficiency was identified for one resident who was not notified by the facility when her family member was no longer allowed to visit due to safety concerns. The resident, who had diagnoses of dementia, adjustment disorder, and depression, reported feeling lonely and isolated, and stated she missed her family member, who had not been allowed to visit for several months. She also stated she never received any policy or notice about the visitation restriction. Interviews with facility staff, including the former DON, social worker, administrator, and ADON, revealed that the family member was restricted from visiting after incidents involving inappropriate behavior toward a staff member, which led to police involvement. The administrator and other staff members confirmed that the decision to restrict visitation was made for staff safety, but there was no documentation in the resident's medical record regarding the restriction, nor evidence that the resident was formally informed by facility staff. Instead, it was believed that another family member had informed the resident about the restriction. The facility's own policy required informing residents and/or their representatives of their visitation rights and any clinical or safety restrictions. However, the administrator acknowledged that the resident rights policy was not reviewed or followed when addressing the visitation issue, and the incident was handled primarily from the perspective of staff safety. There was no documentation or formal communication to the resident regarding the restriction, resulting in the resident being unaware of her rights and the reasons for the limitation.
Failure to Provide Person-Centered Care and Proper Response After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, and total dependence for activities of daily living was found on the floor by her roommate. Staff failed to immediately assess and respond to the resident's condition according to her care plan and physician orders. The resident was observed to be face down, bleeding from the head, and later complained of hip pain. Despite these symptoms, staff picked the resident up from the floor and placed her in bed before calling 911, potentially causing further harm. The resident's care plan included interventions for fall risk, pain management, and monitoring for complications due to her medical history, which included a stroke, hypertension, and use of anticoagulants. However, staff did not follow these interventions. The resident's verbal complaints of pain were not adequately addressed, and her prescribed PRN pain medication was not administered as ordered. Additionally, the staff left the resident and her roommate alone in the room after the incident, contrary to expectations for supervision and safety. EMS documentation and hospital records confirmed that the resident sustained a right femoral fracture, head laceration, and brain bleed. The EMS report noted that the resident was found on the bed with no sheets, indicating she had been moved from the floor by staff prior to their arrival. Interviews with staff revealed inconsistencies in the assessment and response to the fall, with some staff unsure of the appropriate actions to take and others acknowledging that the resident's position and complaints of pain were not properly addressed before moving her. The failure to follow established protocols and care plans resulted in significant injury and ultimately the resident's death.
Failure to Ensure Safe Transfer After Resident Fall Resulting in Injury
Penalty
Summary
A deficiency occurred when facility staff failed to ensure a resident was free from accident hazards and received adequate supervision and assistance during a transfer after a fall. The resident, an elderly female with a history of stroke, severe cognitive impairment, hemiplegia, and total dependence for activities of daily living, was found face down on the floor. Despite her verbal complaint of hip pain, staff lifted her from the floor and placed her in bed without proper precautions, potentially causing further harm. The resident sustained multiple injuries, including a laceration above the eye, a closed head injury, and a broken femur. Interviews and record reviews revealed that staff did not follow appropriate assessment and transfer protocols. Staff acknowledged hearing the resident complain of hip pain but proceeded to move her, with one staff member later admitting that moving the resident could have caused further injury. The facility's policy required a two-person lift with specific support for the head, torso, and hips, but staff described lifting the resident by her head, legs, and ankles, which was not in accordance with policy. Further interviews with nursing and administrative staff indicated inconsistent understanding and application of fall and transfer protocols. Some staff believed it was acceptable to move the resident after a basic assessment, while others stated that a resident with pain or possible injury should not be moved until EMS arrived. Documentation of assessments and vital signs was incomplete, and there was confusion about the correct procedure for transferring a resident after a fall, especially when injury was suspected.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for two residents. For one resident with a history of stroke, hypertension, and severe cognitive impairment, a nurse administered a non-scheduled aspirin as a PRN pain medication without a physician's order, despite the resident having a known head injury. The resident's medication administration record did not reflect an order for PRN aspirin, and facility policy required medications to be administered only as ordered by the physician and documented accordingly. For another resident with diagnoses including anemia, renal failure, dementia, and a history of chronic urinary tract infections (UTIs), the facility failed to ensure the resident received prescribed IV antibiotic therapy as ordered by the physician. The resident was discharged from the hospital with orders for Tobramycin to be administered post-dialysis, but due to miscommunication between the facility, dialysis center, and hospital, the medication was not administered. Facility staff became aware that the medication had not been given only after discovering the initial dose was still in the refrigerator days later. Attempts to administer the medication at the facility were unsuccessful due to the resident's refusal of IV insertion, and there was no evidence that the nephrologist was consulted for alternative arrangements in a timely manner. Interviews and record reviews revealed that staff did not consistently communicate medication refusals or administration issues to the resident's family or the prescribing physicians. Documentation was incomplete regarding the administration or refusal of medications, and there was a lack of follow-up to ensure the resident received necessary antibiotic therapy. These failures resulted in residents not receiving medications as ordered and not having medication administration properly documented, as required by facility policy.
Inadequate Hand Hygiene Practices in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices by staff members. Specifically, CNA W did not follow proper hand hygiene protocols during incontinence care for a resident. CNA W was observed using the same gloves to handle clean wipes, apply barrier cream, and change the resident's brief without washing hands before or after the procedure. This resident, who was moderately cognitively impaired and required extensive assistance with activities of daily living, was at risk due to these lapses in infection control. Additionally, the wound care nurse did not practice hand hygiene before and after assessing another resident's heels. The nurse entered the resident's room, applied gloves without washing or sanitizing hands, and left the room without performing hand hygiene after removing the gloves. Both staff members acknowledged the importance of hand hygiene in preventing infections, yet failed to adhere to the facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent the spread of infections.
Failure to Ensure Privacy During Catheter Care
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident during Foley catheter care. The resident, a male with a history of dementia, urinary retention, acute kidney failure, hydronephrosis, benign prostatic hyperplasia, and diabetes mellitus, was observed in bed with an indwelling Foley catheter. During a scheduled catheter care session, two CNAs provided care without closing the blinds to the resident's window, thereby compromising the resident's privacy. The resident's care plan included interventions to promote dignity by ensuring privacy during personal care. However, during the catheter care, the CNAs did not adhere to this aspect of the care plan. An interview with one of the CNAs revealed an acknowledgment of the oversight, rating her performance as 7.5 out of 10 due to the failure to close the blinds. The Director of Nursing confirmed that privacy should be provided during care to promote dignity, aligning with the facility's policy on dignity, which emphasizes maintaining and protecting resident privacy during personal care.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to the development of a pressure ulcer on the resident's right heel. The resident, a male with multiple diagnoses including dementia, diabetes mellitus, and impaired mobility, was admitted without any pressure ulcers. However, the care plan identified a potential for pressure ulcer development due to impaired mobility, with interventions such as weekly skin assessments and floating heels as tolerated. Despite these interventions, the resident developed an unstageable pressure wound on the right heel, measuring 6cm x 7.5cm, which was observed during a care session. During an observation, the resident was found in bed without his heels being offloaded, and no heel protectors were in use, despite the presence of heel protectors in the resident's drawer. Interviews with the CNA and RN revealed that it was the responsibility of both the nursing staff and CNAs to ensure the resident's heels were offloaded to prevent pressure injuries. The facility's policy on skin and wound management emphasized the importance of preventing new pressure injuries and providing necessary treatment for existing ones, which was not adhered to in this case.
Inadequate Incontinence Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, a female with a history of urinary tract infection, cerebrovascular disease, muscle wasting, type 2 diabetes, and morbid obesity, was always incontinent of bowel and bladder and required extensive assistance with all activities of daily living. During an observation, a CNA did not perform proper perineal care by failing to open the labia to clean and not wiping around the buttocks after an incontinent episode. The CNA, despite being deemed competent in performing perineal care, acknowledged the importance of proper cleaning to prevent infections. The facility's policy on perineal care, which includes specific steps for cleaning the perineal and rectal areas, was not followed. The Director of Nursing confirmed that not adhering to these procedures placed residents at risk of urinary tract infections.
Failure to Label Oxygen Humidifier
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, as evidenced by the lack of proper labeling on the resident's oxygen humidifier. The resident, a [AGE] year-old with multiple medical conditions including chronic obstructive pulmonary disease and dementia, was observed with an unlabeled oxygen humidifier. The resident's care plan and physician's orders specified the need for continuous oxygen therapy and regular changes of the oxygen tubing and humidifier bottle. However, the humidifier was not labeled with the date it was last changed, which is a requirement according to the facility's policy. During an interview, a Licensed Vocational Nurse (LVN) acknowledged that the resident often changes the humidifier independently, with supplies provided by family members. Despite this, the LVN admitted that it was her responsibility to ensure the humidifier was labeled correctly, which should have been checked every shift. The facility's policy, last revised in 2007, mandates that oxygen therapy equipment be maintained in a clean and sanitary manner, with pre-filled humidifiers dated and replaced every ten days or as needed. This oversight in labeling could potentially affect the quality of oxygen support provided to residents.
Improper Labeling of Medications in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with professional principles, which included the appropriate accessory and cautionary instructions and expiration dates. During an observation, it was found that the medication carts for Halls 300 and 400 contained several medications, such as Dorzol/Timolol solution, Latanoprost solution, Fluticasone Propionate nasal spray, and various eye drops, that were opened but not labeled with the resident's name or dated. This oversight was confirmed during an interview with a medication aide (MA A), who acknowledged that opened medications should be dated and labeled with the resident's name to determine when they should be discarded. Additionally, the medication room refrigerator contained vials of Tuberculin Purified Protein Derivative (PPD) that were open but not dated. The Director of Nursing (DON) confirmed that all medications must have pharmacy labels, including the open date, to ensure their effectiveness. The lack of proper labeling and patient identifiers on the medications observed was inconsistent with the facility's labeling practices, as outlined in their policy. The DON stated that medications lacking patient names could no longer be used and must be discarded, as the use of multidose PPD containers without an open date could lead to medication errors.
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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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