Northgate Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 5757 N Knoll, San Antonio, Texas 78240
- CMS Provider Number
- 455804
- Inspections on file
- 49
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Northgate Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an adequate supply of clean towels, resulting in multiple residents missing scheduled showers and bed baths. Observations of linen closets on several halls over multiple days showed very few towels available, and there were no documented shower refusals in the records of cognitively intact and cognitively impaired residents with complex medical conditions, including morbid obesity, quadriplegia, seizures, CHF, dementia, pressure ulcers, UTIs, and cellulitis. Several residents reported going days or about a week without showers or bed baths because staff told them there were no towels and did not return as promised. CNAs and an LVN confirmed ongoing towel shortages, described the towels as too small and thin, and reported having to use blankets at times. The housekeeping supervisor, ADON, and administrator all acknowledged a towel shortage and issues with towels shrinking or being the wrong size.
Multiple residents who required assistance with bathing did not receive their scheduled Monday/Wednesday/Friday showers, and there was no documentation of shower refusals in their records despite care plans and MDS assessments indicating ADL self-care deficits and a need for help with bathing. Observations of linen closets on several halls over multiple days showed very few towels available, and residents reported going days or weeks without showers or bed baths because staff said there were no towels and did not return as promised. CNAs and an LVN confirmed a towel shortage, describing the towels as very small and thin and stating that some showers were missed due to lack of towels, while supervisory staff acknowledged a towel issue that had caused problems with showers, in conflict with facility policies on resident rights, dignity, and bath/shower documentation.
The facility failed to ensure meals were served palatable and at safe, appetizing temperatures. Multiple residents who ate in their rooms reported their food was always cold. Surveyors observed a CNA transporting a meal cart with doors left open during tray pass and a resident with bilateral hand contractures whose meal lid was removed several minutes before feeding began. In another observation, an RN opened a meal cart to check trays and a CNA passed trays on two halls with the cart door open before a sample tray was tested, revealing coleslaw and fruit served too warm and hot items, including shrimp and tater tots, below the dietary manager’s stated hot-holding expectations. The dietary manager and ADMIN confirmed that foods should be served within appropriate temperature ranges, and the facility’s policy required residents receive a nourishing, palatable diet.
Staff failed to perform required hand hygiene while distributing and serving meal trays and assisting with feeding on two halls and in the dining room. A CNA repeatedly passed room trays to all observed residents on two halls without sanitizing hands, while a dietary staff member delivered optional meal items to residents’ rooms without hand hygiene. An LVN checked dining room trays for accuracy and handed them to other staff without sanitizing hands, frequently touching personal clothing, hair, face, and environmental surfaces between trays. The Administrator was also observed moving between residents while providing feeding assistance without washing or sanitizing hands. Staff and leadership later acknowledged that hand hygiene is expected before and after resident care, including meal service, and the facility’s infection control policy requires hand hygiene after touching a resident’s environment.
A cognitively intact male resident with schizoaffective disorder, vascular dementia, and major depressive disorder repeatedly expressed a desire and plan to discharge to a community group home and asked the SW for assistance. The SW began helping and confirmed with the resident’s sister that the family supported this plan, but reported that the ADMIN then ordered her to stop the discharge process and warned she could be fired if she continued discharging residents. The SW told the resident she could no longer help him, and the resident reported feeling sad and that the facility was keeping him there for financial reasons. The ADMIN later stated she was unaware of an active discharge request, despite recalling a prior conversation about the resident wanting to live independently. Surveyors determined the facility failed to assist the resident in exercising his right to discharge and failed to protect him from interference and coercion, contrary to the facility’s resident rights policy.
Surveyors found that the facility did not provide a dignified dining experience for several residents who required assistance with eating. Residents with physical or mental impairments, including those in specialized chairs with upper extremity contractures, had trays and uncovered food placed in front of them for extended periods without staff assistance, while nearby tablemates were already eating. In multiple instances, a resident either waited significantly longer than tablemates to receive a tray or received a tray but no timely feeding help, despite CNAs confirming the residents could not self-feed. Interviews with the DM, ADON, and the administrator confirmed that these practices were inconsistent with facility expectations and written policies requiring simultaneous plate delivery at tables, immediate feeding assistance for dependent residents, and a dignified dining experience.
Surveyors found that non‑nursing staff, including the Administrator and a Medical Records clerk, were assisting multiple dependent residents with eating without documented completion of a State‑approved feeding assistant training course. Observations showed residents with bilateral upper extremity weakness, contractures, inability to lift their arms, and reliance on verbal prompts to open their mouths being fed by these staff. Interviews with HR, the ADON, the ADMIN, and the RNC revealed confusion about where feeding assistance training was housed, missing or unavailable training records, and in‑service sheets that did not include the ADMIN or MR clerk as attendees. Record review from hire to current date confirmed no documented feeding assistant training for these staff, and the ADMIN reported the facility had no policy on feeding assistant training, despite regulatory requirements. The report states this failure could place residents who require assistance with eating at risk of aspiration and choking.
Surveyors found that the exit door alarm at the end of hall 100 was turned off, even though multiple non-ambulatory residents lived on that hall. During door checks with the Maintenance Director, the door failed to alarm when opened until he used a key to re-activate the mounted alarm box. The Maintenance Director reported that CNAs had keys and sometimes used the door to take residents outside, and he stated he normally checked exit doors weekly. The DON and ADMIN both stated their expectation that exit door alarms remain active and be re-armed after use, and acknowledged that a disabled alarm could allow a resident to exit without staff awareness, contrary to the facility’s wandering and elopement policy.
A resident with multiple comorbidities, including a chronic wound, colostomy, indwelling catheter, and ostomy, had active orders and posted signage for Enhanced Barrier Precautions (EBP), requiring staff to use gown and gloves during high-contact care such as wound care. During an observation, an LPN performed right upper arm wound care on the resident without wearing a gown, despite the EBP sign and the facility’s written policy specifying gown and glove use for wound care. In interviews, the DON and Administrator confirmed that staff were expected to wear gowns and gloves for residents on EBP and acknowledged that not doing so placed the resident and staff at risk for infection.
Surveyors found that required daily nurse staffing and census information was not posted at the beginning of, or within two hours of, a day shift. A document for the prior day’s staffing remained posted in the lobby until midday, when the correct day’s staffing sheet was finally posted. The DON reported that a weekend supervisor is normally responsible for posting this information, but the supervisor was absent and the task was completed late by the ADMIN, with no clear backup process identified. The ADMIN confirmed the posting is intended to inform the public of RN, LPN, CNA, and other direct care staffing per shift, consistent with facility policy requiring timely computation and posting of these data.
A resident with severe cognitive impairment and incontinence was left unattended for several hours, resulting in exposure, soiled clothing, and unsanitary room conditions. Staff failed to perform required rounds or follow the care plan, leading to the resident remaining in an undignified state with urine and feces present in the room. Interviews confirmed that staff were aware of the need for frequent checks but did not carry them out.
A resident with severe cognitive impairment and total incontinence was found in an unsanitary room with urine and feces on the floor, sticky tiles, and a strong odor. Staff interviews revealed that required rounds and cleaning were not performed as needed, and the resident was left without proper assistance or hygiene. Facility leadership acknowledged the failure to provide a safe and clean environment as required by policy.
Two residents experienced failures in timely reporting of suspected neglect and possible misappropriation of narcotic medications. In one case, a resident returned from leave with missing narcotic medication records, and staff did not follow required procedures for counting and documenting controlled substances or report the incident as possible misappropriation. In another case, a resident reported feeling neglected during her first week, but the allegation was not promptly reported to the administrator or authorities as required by policy.
A resident with multiple complex medical conditions, including a colostomy, was admitted without a completed baseline care plan reflecting her need for colostomy monitoring and care. Although nursing staff provided colostomy care as needed, the required instructions were not documented in the baseline or comprehensive care plans within the required timeframe, as confirmed by the DON and facility records.
A resident with cognitive impairment and a history of smoking-related safety issues was allowed to smoke under staff supervision without the required protective smoking apron, despite documented care plan interventions and facility policy. Staff interviews confirmed knowledge of the resident's need for the apron, but it was not enforced during the observed incident.
A resident prescribed opioid medications was allowed to leave the facility on pass without proper accounting or documentation of his controlled substances. An agency nurse provided the resident with his medications without conducting a two-nurse count or ensuring the required narcotic sheets were completed. Upon the resident's return, staff discovered the narcotic sheets were missing and had to create new documentation to account for the remaining medications. Facility leadership acknowledged that established protocols for handling controlled substances were not followed.
A resident admitted with a stage 4 sacral wound did not have Enhanced Barrier Precautions (EBP) implemented as required. Staff provided wound care using gloves but not gowns, and there was no PPE bin or signage outside the room. Despite documented training on infection control and EBP, staff were unaware of the need for EBP, and the care plan did not include appropriate interventions.
A resident with severe obesity and mobility limitations did not receive appropriate assessment or timely maintenance of their motorized wheelchair, resulting in prolonged use of equipment that may not have met their weight requirements. Facility staff failed to verify the wheelchair's specifications, coordinate necessary repairs, or refer the resident for a therapy evaluation, despite ongoing mechanical issues and clear indications that the facility was responsible for providing suitable DME. This led to the resident experiencing unsafe mobility and reduced independence.
A resident with severe cognitive impairment and a history of falls was left unsupervised in bed, which was not lowered to the required position, despite care plan directives and facility policy. A CNA admitted to forgetting to lower the bed after transferring the resident, and the DON confirmed the resident's high fall risk and need for the bed to be in the lowest position. No staff were present to supervise the resident, who was observed moving and reaching for items on the floor.
Surveyors found that the facility did not maintain a sanitary shower environment, with soiled linens and towels left in the shower room after use, and failed to ensure that two residents received required tuberculosis (TB) screenings at admission and annually. These deficiencies were confirmed through observations, interviews, and record reviews, and involved residents with complex medical conditions and varying cognitive status.
A resident with morbid obesity and multiple medical conditions did not receive a recommended bariatric bed and overhead trapeze, despite therapy and physician orders. The resident continued to use an inadequate bed, and staff interviews revealed delays and lack of documentation regarding the equipment order, resulting in unmet accommodation needs.
A resident with severe cognitive impairment and multiple medical conditions was unable to receive visitors after 8:00PM due to the facility's locked front door and lack of staff response to the doorbell. Despite repeated requests from the resident's POA and discussions among leadership about possible solutions, no effective measures were implemented, resulting in the resident's visitation rights not being honored according to facility policy.
Two residents were unable to access or use telephones for private communication due to a combination of visual impairment, lack of personal devices, and a non-functioning facility cordless phone. One resident's emergency contact reported calls to the facility were rarely answered, while another resident was repeatedly told the hallway phone was not working. Facility leadership and maintenance confirmed the phone was inoperable and no alternative was provided for those unable to use personal phones, resulting in a failure to ensure reasonable access and privacy for resident communication.
A resident who was assessed as a safe smoker was found to have cigarettes and a lighter in her room, in violation of facility policy requiring all smoking materials to be stored securely and smoking to be supervised. Staff interviews revealed inconsistent enforcement of the policy, and required documentation for tracking smoking materials was not maintained, resulting in a deficiency related to accident hazard prevention and supervision.
A resident with complex medical needs did not consistently receive the physician-ordered therapeutic diet, including double portions of protein and vegetables, due to food budget restrictions, lack of clear guidance on vegetable servings, and insufficient food supplies. Staff interviews and kitchen observations confirmed that prescribed dietary needs and resident preferences were not met, and facility policy requirements for therapeutic diets were not followed.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental risks and insufficient staff monitoring.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
A resident with severe cognitive impairment and multiple diagnoses was administered Olanzapine, an antipsychotic medication, without documented informed consent in the medical record. Staff interviews revealed unclear responsibility for obtaining psychotropic medication consents, and the required consent form was not present, despite facility policy requiring residents to be informed and to provide consent for such medications.
A resident with severe cognitive impairment and high assistance needs was observed in bed with her call light on the floor, out of reach and not visible. Staff confirmed the call light was not accessible, despite facility policy requiring it to be within reach for all residents.
A resident with a feeding tube did not have their enteral feeding formula and water containers properly labeled or discarded after use. Observations showed that the containers remained hanging and unlabeled after feedings, and staff were unsure about the timing and reuse of the formula. Facility policy required labeling and timely disposal, but these steps were not followed, as confirmed by both nursing staff and the DON.
A resident with complex medical needs was discharged to the hospital and not readmitted, but the facility failed to provide required discharge documentation, including a 30-day notice, physician orders, and a discharge summary in the EMR. Staff interviews indicated the decision was based on concerns about non-compliance and suspected drug use, but the facility did not follow its own policy for discharge notification and documentation.
Two residents made separate allegations of abuse, including inappropriate touching and being hit by another resident, but these incidents were not reported to the state agency or investigated as required. Staff interviews revealed that decisions not to report were based on factors such as cognitive scores and lack of witnesses, despite facility policy mandating immediate reporting of all abuse allegations.
Two residents made separate allegations of abuse and mistreatment, including inappropriate touching and being hit by another resident. Despite documentation by an LPN and awareness by the DON and administrator, neither incident was thoroughly investigated or reported as required by facility policy. Staff interviews revealed inconsistent application of reporting protocols, with decisions influenced by residents' cognitive status and lack of witnesses.
A facility failed to maintain a safe and clean environment for a resident, as a pile of yellow liquid, identified as urine, was found on the restroom floor. The resident, with multiple health issues including incontinence and unsteady gait, was at risk of falls due to this oversight. The care plan included measures to prevent such incidents, but they were not effectively implemented.
A medication cart in the facility was found unattended and unlocked, containing medication blister packs. LVN A, not assigned to the cart, acknowledged it should have been locked. The DON confirmed the cart was used for storage and was unaware of its last access. Facility policy requires secure storage of medications.
The facility failed to employ a certified dietary manager, placing residents at risk of foodborne illness and inadequate nutrition. The dietary manager, hired without the necessary certification, was unaware of the requirement. Interviews with the HR Director and Administrator revealed they were also unaware of the certification requirement, despite the facility's handbook mandating current licensure and certification for staff.
The facility failed to properly label and date food items in the refrigerator, and the dish machine's temperature gauge was non-functional, posing a risk of foodborne illness. Snacks in the Nourishment Rooms were also not consistently labeled or dated, and there was a lack of cleaning in the refrigerators. Interviews revealed that these issues were known but not adequately addressed, with no work order found for the dish machine repair.
The facility failed to provide a safe and sanitary environment, with issues such as a disconnected bathroom ceiling fan, broken light fixtures, and missing ceiling panels. The Maintenance Director had recently left, and there was no preventative maintenance policy in place, leading to unaddressed deficiencies.
The facility failed to maintain an effective pest control program, with numerous gnats and flies observed on the 200 hall and a cockroach in the conference room. The maintenance person responsible for pest control had quit, leaving the facility without proper oversight. The facility had a contract with a pest control company, but the issue persisted.
A facility failed to include a resident's use of the anticoagulant medication Eliquis in their care plan, despite its importance for treatment monitoring. Interviews with the DON and MDS LVN-A confirmed the omission, which was contrary to the facility's policy requiring comprehensive care plans with measurable goals.
A resident with severe impairments and a mechanically altered diet was left unsupervised during meals, contrary to care plan requirements. Observations showed the resident eating alone without necessary adaptive equipment, increasing the risk of choking. Staff interviews revealed communication gaps and failure to implement recommended supervision, leading to a deficiency in care.
The facility failed to maintain a clean and safe environment for residents, with issues such as a black substance in a toilet, peeling drywall, and unclean floors. Housekeeping and maintenance staff were aware of these problems but did not adequately address them, leading to discomfort and dissatisfaction among residents.
The facility failed to develop comprehensive care plans for two residents, leading to unmet needs and potential risks. One resident, with severe impairments and a history of dysphagia, was not properly supervised during meals despite recommendations for dining room supervision. Another resident, with a history of falls, had improper use of fall mats not addressed in her care plan. The lack of coordination and communication among staff resulted in these deficiencies.
A resident's medication was improperly stored when a nurse left a furosemide pill unattended on the bedside table, contrary to facility policy. The resident, who was cognitively intact but visually impaired, took the pill without supervision. The DON confirmed that medications should not be left unattended to prevent misuse or health risks.
A resident with severe impairments and on a mechanically altered diet was served a hard piece of toast, inappropriate for his dietary needs, and lacked necessary meal items. The dietary manager admitted the bread was overcooked and the gelatin snack was improperly prepared, highlighting the facility's failure to provide meals in the correct consistency.
A resident with a documented allergy to mushrooms did not have this allergy listed on their dietary form, leading to a failure in communication between nursing and dietary staff. The Dietary Manager was unaware of the allergy, and the Director of Nursing acknowledged the potential for a severe allergic reaction. The facility's policy on nutritional recommendations was not adhered to, resulting in this deficiency.
A resident with significant health issues, including dysphagia, was not provided with drinks consistent with their needs during meal service, lacking water and appropriate drinking aids like lids and straws. The resident's care plan required specific meal setup assistance, which was not fully implemented, leading to a deficiency in hydration support.
A resident with a history of stroke and multiple diagnoses requiring assistance with eating was not provided with the necessary special eating equipment, specifically a divided plate, as per their care plan and physician orders. Observations showed the resident struggling to eat with a regular plate, leading to food spillage and the resident eating with his hands. Interviews confirmed the oversight, despite the facility's policy outlining the need for adaptive equipment.
Inadequate Towel Supply Resulting in Missed Showers and Bathing
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring adequate clean towels were available for resident showers and bathing. Multiple linen closet observations on different halls over several days showed very limited numbers of towels available at any given time, with as few as four to seven towels per hall. The facility had no specific policies for towels, and there was no documentation in the medical records of shower refusals for the residents reviewed, despite their reports of missed showers. Several residents with significant medical and functional needs reported not receiving regular showers or bed baths because staff stated there were no towels. One male resident with morbid obesity, psychoactive substance abuse, and major depressive disorder, who was cognitively intact, stated he did not get showered regularly and that staff told him it was due to a lack of towels, and that he had informed management multiple times. A female resident with seizures, left-sided hemiplegia, morbid obesity, intracerebral hemorrhage, and congestive heart failure, with moderate cognitive impairment, reported she had not had a bed bath in about a week because staff said there were no towels and that promised baths were not completed. Another cognitively intact female resident with quadriplegia, pressure ulcer, UTIs, irritant contact dermatitis, and major depressive disorder stated she went days without a shower for the same reason and that when she requested a shower the next day, staff told her it was not her scheduled day. A cognitively intact female resident with dementia without behavioral disturbance, major depressive disorder, a left knee contracture, and cellulitis reported she was supposed to receive three showers per week but only received one due to towel shortages. Staff interviews confirmed ongoing towel shortages affecting the ability to provide showers. A CNA reported frequent difficulty obtaining towels, sometimes resorting to using blankets, and stated that the towels purchased were very small and thin, requiring several per shower. An LVN stated there was a towel shortage, sometimes leaving only about ten towels for the day, and that multiple towels were needed to shower a resident. Another CNA stated that overnight staff just washed linen when needed and that there was never any linen. The housekeeping supervisor and the administrator both acknowledged a towel shortage, with the housekeeping supervisor stating towels had shrunk in the dryer and the administrator stating that towels delivered had shrunk and that the company kept sending the wrong size. The ADON also acknowledged a towel issue and that some showers were missed because of it.
Failure to Provide Scheduled Showers and Adequate Linens for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically bathing and hygiene, to multiple residents who required help. Four residents, all assessed as needing assistance with bathing on their MDS assessments, did not receive showers according to their scheduled Monday/Wednesday/Friday shower routines. For one male resident with morbid obesity, psychoactive substance abuse, and major depressive disorder, the shower task list showed missed showers on multiple date ranges throughout the month, and there was no documentation in progress notes of any shower refusals. His care plan identified an ADL self-care performance deficit, but there was no indication that his lack of showers was due to his choice or refusal. A female resident with seizures, left-sided hemiplegia, morbid obesity, nontraumatic intracerebral hemorrhage, and congestive heart failure was also care planned for an ADL self-care deficit and risk for urinary tract infections and pressure ulcers. Her quarterly MDS showed she needed assistance to bathe, and her shower task list documented that she did not receive any showers for the entire month reviewed. Her care plan did not mention any refusal of care or showers, and progress notes contained no documentation of shower refusals. Another female resident with quadriplegia, a pressure ulcer of the left buttock, recurrent UTIs, irritant contact dermatitis due to incontinence, and major depressive disorder, also assessed as needing assistance with bathing, missed numerous scheduled showers over multiple date ranges. Her care plan included impaired skin integrity related to immobility and incontinence and a self-care performance deficit related to quadriplegia, yet progress notes contained no documentation of shower refusals. A fourth female resident with dementia without behavioral disturbance, major depressive disorder, a left knee contracture, and cellulitis, who also required assistance with bathing, missed several scheduled showers over multiple stretches of days according to the shower task list. Her care plan included risk for depression, communication problems, contracture, artificial hip, and incontinence, but there were no documented refusals of showers in her progress notes. Observations of linen closets on multiple halls over several days showed very limited numbers of towels available at any given time. Multiple residents reported not receiving regular showers or bed baths because staff told them there were no towels, and that staff sometimes promised to return later but did not. CNAs and an LVN confirmed there was a towel shortage, described the towels as very small and thin, and stated that some showers were missed due to lack of towels. The housekeeping supervisor, ADON, and administrator all acknowledged a towel issue or shortage that had caused problems with showers. Facility policies on resident rights, dignity, and bath/shower protocol required that residents be groomed as they wish, allowed to choose when to conduct ADLs, and that staff document when showers are given or refused, but the documentation and interviews showed that required showers were not consistently provided or documented for these residents.
Failure to Maintain Safe and Palatable Food Temperatures During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide food and drink that were palatable, attractive, and maintained at safe and appetizing temperatures during meal service. Confidential resident interviews revealed that multiple residents who ate meals in their rooms on two different halls reported their food was always cold. During one observation of meal service, a CNA pushed a meal tray cart down a hall with both cart doors open during tray pass, only closing them briefly when transitioning between halls and then leaving them open again while passing trays. In another observation, a meal tray was placed in front of a resident with bilateral hand contractures, and the warming lid was removed several minutes before an unidentified CNA began feeding the resident, allowing additional time for the food to cool. During a separate observation of meal tray preparation and delivery, the surveyor arranged to receive a tray from the last cart sent out of the kitchen. The cart for two halls was delivered to nursing staff, and an RN opened the cart to check tray accuracy. A CNA then began passing trays on one hall with the cart door open, moved the cart to the next hall, and continued tray pass before the surveyor retrieved the sample tray at the end of the pass. Temperature checks on this tray showed coleslaw at 86.0°F, boiled shrimp at 96.4°F, tater tots at 97.5°F, hushpuppies at 103.6°F, and fruit at 70.9°F, which were not within the dietary manager’s stated expectations that cold items be closer to 40°F and hot items not be under 100°F. The dietary manager and the administrator both acknowledged that foods should be served within appropriate temperature ranges and that the coleslaw and shrimp temperatures were incorrect. The facility’s Food and Nutrition Services policy stated that each resident is to be provided with a nourishing, palatable, well-balanced diet that meets nutritional and special dietary needs while considering resident preferences.
Failure to Perform Hand Hygiene During Meal Tray Distribution and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff performed hand hygiene while storing, preparing, distributing, and serving food under sanitary conditions during multiple meal services on the 100 and 200 halls and in the dining room. On two consecutive days, a CNA passing room trays did not sanitize her hands before or after passing meal trays to all observed residents on both halls, despite the meal cart doors being open during the tray pass. A dietary staff member was also observed passing out meal trays with optional meal items to residents in their rooms without sanitizing hands before or after entering the rooms. In the dining room, an LVN checking meal trays for accuracy and handing them to other staff for distribution did not sanitize her hands before or after touching trays and was observed repeatedly touching the meal cart, her scrubs, her hair, her face, the doorframe, and other environmental surfaces between handling trays. On the following day, the same CNA again passed room trays to all observed residents on both halls without performing hand hygiene before or after handling the trays. The same LVN again checked dining room trays for accuracy and handed them to staff without sanitizing hands, while touching her face, scrubs, hair, the tray rack, and the door and doorframe between trays. Additionally, the Administrator was observed switching between residents for feeding assistance without washing or sanitizing hands between residents. In interviews, the CNA, ADON, and Administrator each stated that staff are expected to perform hand hygiene before and after providing care, including passing and assisting with meals, and acknowledged that failure to do so could result in residents acquiring an infection. The facility’s Infection Control Policy for Handwashing/Hand Hygiene indicated that hand hygiene is required after touching a resident’s environment.
Failure to Honor Resident’s Right to Discharge and Freedom from Coercion
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination and to exercise his rights without interference, coercion, discrimination, or reprisal. The resident was an adult male with diagnoses including suicidal ideation, schizoaffective disorder (bipolar and depressive types), vascular dementia without behavioral disturbance, and major depressive disorder. Despite these conditions, his most recent MDS showed a BIMS score of 13, indicating he was cognitively intact, and he was noted to ambulate independently, require only supervision or be independent for ADLs, and place high importance on his daily preferences. His care plan documented that he was a smoker, left the facility when he wanted to, enjoyed sitting outside, and preferred his own routine. Progress notes from a quarterly care plan meeting documented that the resident had expressed a desire to move into the community to a group home and had asked the social worker (SW) to help him locate a group home around a specific monthly cost. The SW reported that she attempted to help the resident find an outside group home and contacted the resident’s sister, who confirmed that the original plan from admission was for the resident to move to a group home after about a year, once he was more stable. The SW stated that after informing the administrator (ADMIN) that the sister supported the move, the ADMIN directed her to stop the discharge process, citing the family’s wishes, and told her that if she continued discharging patients she would be let go. The SW then told the resident she could not help him with discharge and informed the sister that she had been told to stop assisting. During interviews, the resident stated that he wanted to discharge and believed that had been the plan from admission, and he reported that the SW told him she could not move him or she would be fired. He stated this made him sad and expressed that he felt the facility wanted to make money off him and was finding reasons to keep him there. The ADMIN stated she was not aware the resident was attempting to discharge and claimed he had not told her he wanted to go, though she recalled a prior conversation in which he said he wanted to live independently and go to nursing school. The facility’s resident rights policy stated that residents should be able to exercise their rights without interference, coercion, discrimination, or reprisal from the facility. The surveyor’s findings concluded that the facility failed to allow and assist the resident to exercise his right to discharge to an outside provider per his request and failed to ensure his rights to be free from interference were respected, placing him at risk of low self-esteem, increased depression symptoms, breakthrough suicidal ideation, and embarrassment due to the facility’s accusations that he would not be successful outside the facility.
Failure to Provide Dignified, Timely Dining Assistance to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide a dignified and respectful dining experience for multiple residents who required assistance with eating. On several observed occasions, residents who were unable to feed themselves due to physical or mental handicaps had trays placed in front of them with food left uncovered for extended periods before staff began feeding them. In one instance, a resident with an uncovered plate in front of them waited from 12:10 p.m. until 12:22 p.m. before a CNA sat down to provide feeding assistance. In another observation, a resident seated in a specialized chair with bilateral upper extremity contractures had an uncovered plate placed in front of them at 12:17 p.m., but staff did not begin assisting the resident to eat until 12:25 p.m. CNAs confirmed that these residents required feeding assistance. Additional observations showed residents at tables experiencing delays in receiving their meals or in receiving assistance to eat while their tablemates were already eating. On one day, a resident seated with two tablemates did not receive a tray until 12:20 p.m., and despite tray setup, did not receive feeding assistance until 12:23 p.m. due to physical handicaps preventing self-feeding. In another case, a resident at a table did not receive a tray until 12:20 p.m. and was not assisted to eat until 12:24 p.m., while tablemates were already eating. On a separate day, one resident at a table was assisted and finished eating while a tablemate had not yet received a meal; a different resident was then seated and served at the same table before the original tablemate received a plate at 12:22 p.m., and that resident did not receive feeding assistance until 12:24 p.m. Interviews with the DM, ADON, and Administrator confirmed that facility expectations and written policies require residents at the same table to receive plates without gaps, that residents needing assistance should be served when staff are immediately available to assist, and that residents are to be provided a dignified dining experience and adequate staff assistance with eating.
Untrained Non‑Nursing Staff Providing Feeding Assistance Without Required Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff who were assisting residents with eating had successfully completed a State‑approved feeding assistant training course before providing this care. Over a three‑day observation period, surveyors observed the Medical Records (MR) clerk and the Administrator (ADMIN), both non‑nursing staff, feeding three unknown residents in the dining room who required full feeding assistance. One resident had bilateral upper extremity weakness and contractures, another sat upright in a specialized chair and did not attempt to lift either upper extremity, and another sat slightly hunched over and was not trying to lift their upper extremities. A further resident only opened their mouth for the ADMIN when verbally prompted. In each instance, CNA D confirmed that these residents needed feeding assistance. The report states that this failure could place residents who require assistance with eating at risk of aspiration and choking. During interviews and record reviews, the facility was unable to produce documentation that the ADMIN and MR clerk had completed a State‑approved feeding assistant training course. The HR representative stated that feeding assistance training was not part of the new hire packet, that some trainings were done as in‑services or department‑specific, and that paper copies could not be located, partly due to a change in company systems. HR later provided pre‑acquisition training paperwork that did not include feeding assistance training and acknowledged that the training for feeding assistance might not auto‑populate in the new system. The ADON believed feeding assistance training was included in dementia training and said it might be in Relias or in the DON’s office, but no documentation was produced. The ADMIN confirmed she could not locate training records and the in‑service sheets she provided did not list her or the MR clerk as attendees. The RNC verbally verified that the ADMIN and MR clerk had been present for training but had no signed documentation. Record review from hire to current date for the ADMIN and MR clerk showed no completed feeding assistance training, and an in‑service sheet for feeding assistance lacked their signatures. The ADMIN also stated the facility did not have a policy on training for feeding assistance, despite regulatory requirements that non‑nursing staff must complete a State‑approved course before assisting residents with feeding.
Exit Door Alarm on Hall 100 Found Disabled, Creating Elopement Hazard
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when the exit door alarm on hall 100 was found turned off. Record review showed there were 14 residents on hall 100 out of a total facility census of 47 residents. During an observation around midday, staff were present in the hallway and four resident room doors were open, with two residents in bed and two in wheelchairs; these residents were observed to be non-ambulatory and unable to move their wheelchairs independently. Later that afternoon, during a joint observation and interview with the Maintenance Director, seven exit doors were checked, and the exit door at the end of hall 100 did not alarm when the release bar was pushed and the door opened. The Maintenance Director used a key to turn on the mounted red exit door alarm, after which the alarm functioned properly. He stated he did not know why the alarm had been off and reported that CNAs had copies of the key and would occasionally use that door to let residents out for smoking breaks or to take residents out because it was closer to the ramps. He also stated he checked the doors every Monday and that this was the first time he had found an unsecured door. The DON stated her expectation was that staff would turn door alarms back on after disabling them with a key and acknowledged that if an alarm was disabled, residents could get out the door without staff knowing. The Administrator stated she expected fire exit doors to alarm when the handle was pushed and indicated staff would not have a reason to disable an alarm unless taking something out the back of the facility. Facility policy on wandering and elopements indicated the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.
Failure to Use Required PPE Under Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring appropriate use of personal protective equipment (PPE) under Enhanced Barrier Precautions (EBP) during wound care. A cognitively intact resident with diagnoses including cerebral infarction, colostomy status, malignant melanoma of the right upper limb, an indwelling catheter, an ostomy, and open skin lesions had active physician orders for daily right upper arm wound care and for EBP. The EBP orders specified that staff must use gown and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs), and that EBP is indicated for residents with wounds and indwelling medical devices regardless of MDRO colonization. The facility’s EBP policy, revised in March 2024 and February 2025, required targeted gown and glove use for high-contact care activities, including wound care for any skin opening requiring a dressing. On the survey date, an LPN was observed performing right upper arm wound care on this resident without donning a gown, despite an EBP sign posted next to the resident’s door and the active EBP orders. The LPN conducted the wound care while only partially complying with the required PPE, as she did not wear a gown for this high-contact activity. In interviews, the DON stated her expectation that staff wear gloves and gowns when entering and performing care on residents under EBP, and the Administrator stated that door precaution signs inform staff of required PPE, including gowns and gloves, and that she expected staff to wear them. Both the DON and Administrator acknowledged that failure to wear the appropriate PPE, including a gown, placed the resident and staff at risk for infection, demonstrating that the observed practice did not conform to facility policy or provider orders for EBP.
Failure to Timely Post Daily Nurse Staffing and Census Information
Penalty
Summary
The deficiency involves the facility’s failure to post required daily nurse staffing and census information at the beginning of, or within two hours of, the 6:00 a.m. to 6:00 p.m. shift on 03/07/2026. At 12:00 p.m. on that date, surveyors observed that the document posted in the front lobby was labeled as the daily staffing for Friday, March 6th, and contained the census and scheduled number and hours worked for CNAs, LVNs, RNs, hospitality aides, and total hours worked for the two 12-hour shifts. A subsequent observation at 12:49 p.m. showed that the correct document labeled as the daily staffing for Saturday, March 7th, was then posted in the same location, indicating that the required information had not been posted timely for that day’s day shift. During interviews, the DON stated that the weekend supervisor was responsible for posting the daily census and nurse staffing document on weekends, but the weekend supervisor did not work on 03/07/2026. She reported that the administrator posted the document but acknowledged it was posted late and was unsure who served as the weekend supervisor’s backup for this task, adding that she did not know the impact of the late posting because it had never happened before. The administrator stated her expectation was that the weekend supervisor post the daily census and nurse staffing document in the front area, and when there was no weekend supervisor, the manager on duty would usually complete the task. She could not explain why the document was not posted on time and confirmed that the document serves as a notification to the general public about staffing per shift, with the same information also available in a staffing book in the lobby. Policy review showed that the facility’s “Posting Direct Care Daily Staffing Numbers” policy, revised August 2022, requires that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care be computed by the charge nurse or designee and posted in a prominent, accessible location using the Nurse Staffing Information form.
Failure to Maintain Resident Dignity and Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident's right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility. The resident, an older male with multiple diagnoses including chronic obstructive pulmonary disease, muscle weakness, major depressive disorder, vascular dementia, type II diabetes mellitus, and paranoid schizophrenia, was noted to have severe cognitive impairment and was always incontinent of bowel and bladder. His care plan required frequent checks for incontinence and regular cleaning of his room due to his risk for unsanitary behaviors and falls. On the day of the survey, the resident was found sitting in his wheelchair, naked from the waist down, with wet pants on the floor and dried feces smeared from the toilet to the sink. The room had a strong odor of urine and feces, sticky floors, and a pool of liquid identified by the resident as urine. The resident reported that no one had checked on him since breakfast, and he felt bad about the soiled conditions. Staff interviews revealed that the assigned CNA did not perform required rounds or check the care plan, assuming the resident could toilet himself. The CNA acknowledged that the resident was left in an undignified state and that frequent checks were necessary due to his incontinence and behavioral issues. Further interviews with the LVN and DON confirmed that the resident required frequent monitoring and that the room should have been cleaned at least twice daily. The LVN admitted not checking on the resident during the morning hours due to being busy with medications, and the DON stated that the resident's condition and room were unacceptable. Facility records showed that staff had received training on resident rights and dignity, and the facility's policy required all residents to be treated with kindness, respect, and dignity.
Failure to Maintain Safe and Clean Environment for Resident with Incontinence
Penalty
Summary
A deficiency was identified when a resident's right to a safe, clean, comfortable, and homelike environment was not honored. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, muscle weakness, major depressive disorder, vascular dementia, type II diabetes mellitus, and paranoid schizophrenia, was observed in a room with significant sanitation issues. The resident was always incontinent of bowel and bladder, required maximum assistance with activities of daily living except eating, and needed frequent checks and assistance with toileting. Despite these needs, the resident was found sitting in his wheelchair, naked from the waist down, with wet pants on the floor, and a pool of urine on the floor. The bathroom had smeared dried feces extending from the toilet to the sink, and the room had a strong odor of urine and feces with sticky floor tiles. Interviews revealed that the housekeeper assigned to the resident's hall did not start work until later in the morning, and although the floor was mopped twice daily, the sticky substance and feces persisted. The CNA assigned to the resident admitted to not performing rounds or entering the room as required, mistakenly believing the resident could toilet independently. The CNA also acknowledged the resident deserved a clean room and recognized the embarrassment caused by the unsanitary conditions. The LVN assigned to the resident was unaware if rounds had been completed and did not check on the resident during the morning medication pass, stating the resident would not use the call light to request assistance. Facility leadership, including the DON and Administrator, confirmed that the resident required frequent checks and that the room's condition was unacceptable. The DON acknowledged the risk of infection and health issues due to the presence of urine and feces on the floor and accepted accountability for the nursing care provided. Facility policies and job descriptions reviewed indicated a requirement for maintaining cleanliness and a safe environment, but these standards were not met in this instance.
Failure to Timely Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, exploitation, or misappropriation of resident property were reported immediately, as required by federal and state regulations. Specifically, two incidents involving two residents were not reported to the administrator and appropriate authorities within the mandated timeframes. The first incident involved a male resident who went out on leave during Thanksgiving and returned with missing narcotic medication cards for Tramadol and Tylenol #3. The agency nurse who signed him out did not follow the required procedure of counting and documenting the medications with the resident, nor did she provide the necessary narcotic sheets. Upon the resident's return, staff discovered the narcotic sheets were missing, and there was uncertainty about the quantity of narcotics the resident should have had. Although the incident was reported to the DON, it was not reported as a possible misappropriation or drug diversion to the administrator or state authorities as required. The second incident involved a female resident who reported feeling neglected during her first week of admission. She stated that her colostomy bag broke and she was unable to get assistance despite calling for help, and she believed her call light was intentionally misplaced. The resident reported this to the social worker (SW), who then informed the DON but failed to report the allegation to the administrator, who was also the abuse and neglect prevention coordinator. The DON did not recall being informed about the incident, and the administrator confirmed that the incident should have been reported immediately. The facility's own policies and staff training materials required immediate reporting of such allegations, but these procedures were not followed in either case. Record reviews confirmed that neither incident had been reported in the state's TULIP system, and interviews with staff revealed gaps in following established protocols for reporting and investigating allegations of abuse, neglect, or misappropriation. Both residents had significant medical needs, including pain management with controlled substances and complex wound and ostomy care, which heightened the importance of timely and accurate reporting. The facility's failure to report these incidents as required constituted a deficiency in protecting residents' rights and ensuring their safety.
Failure to Complete Baseline Care Plan for Colostomy Care
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who required specialized care, specifically for a colostomy. The resident, a female with multiple complex diagnoses including type 2 diabetes, bilateral above-knee amputations, stage III pressure ulcer, and peripheral vascular disease, was admitted with orders for colostomy care. Despite these needs, the baseline care plan was not completed to reflect her colostomy and the required monitoring and care instructions. The resident's electronic medical record and active orders indicated the necessity for colostomy bag checks and changes, but this was not incorporated into her baseline or comprehensive care plans. Observations and interviews revealed that the resident was experiencing pain and had a colostomy bag in place, with care being provided by nursing staff as needed. However, the Director of Nursing acknowledged that the baseline care plan was opened but not completed, and that the omission of colostomy care instructions could result in missed care. Nursing staff were aware of the resident's colostomy and provided care, but were not informed that the baseline care plan was incomplete. Facility policy required a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, but this was not followed in this case.
Failure to Provide Required Smoking Safety Equipment and Supervision
Penalty
Summary
A deficiency occurred when a resident with vascular dementia, mild intellectual disabilities, and a history of smoking-related safety issues was allowed to smoke without the required protective smoking apron. The resident's care plan and smoking assessment both specified the need for supervision and the use of a smoking apron due to previous incidents of cigarette burns on his clothing and the tendency to rest a lit cigarette near his pants. Despite these documented requirements, the resident was observed smoking under the supervision of a housekeeper without wearing the apron. Interviews with staff confirmed awareness of the resident's need for the apron, with the housekeeper stating the resident refused to wear it and the DON reiterating that smoking should not occur without the apron. The social worker also confirmed the resident was not safe to smoke without the apron, even with supervision, due to his habit of letting the cigarette touch his pants. Facility policies required individualized safety interventions and adherence to smoking safety protocols, but these were not followed during the observed incident.
Failure to Account for Controlled Substances During Resident Pass
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring the accurate accounting and documentation of controlled substances for a resident who went out on pass. The resident, who had intact cognitive status and was prescribed opioid medications for pain management, reported that when he left the facility for a pass, an agency nurse gave him a bag with his medications but did not count the narcotics with him or provide the required narcotic sheets. Upon his return, the resident informed facility staff that the medications were not counted at the time of his departure, and staff subsequently discovered that the narcotic sheets were missing. Facility staff, including two LVNs, counted the medications upon the resident's return and created new narcotic sheets to account for what was brought back. The DON later confirmed that the process for signing out controlled substances was not followed, as there was no two-nurse count, no resident signature for the medications provided, and the narcotic sheets were not given to the resident as per protocol. The DON also acknowledged that the incident was not reported as a potential drug diversion or misappropriation at the time, despite the lack of accountability for the narcotics. Interviews with facility leadership and staff revealed that the agency nurse responsible for the resident's medications was not properly oriented to the facility's procedures for handling controlled substances during resident passes. Facility policies required written prescriber authorization, two-nurse count verification, and documentation in the controlled substance disposition log, none of which were followed in this instance. The failure to adhere to these procedures resulted in a lack of accountability for the resident's narcotic medications during his absence from the facility.
Failure to Implement Enhanced Barrier Precautions for Resident with Stage 4 Wound
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident admitted with a stage 4 pressure wound to the sacrum. Upon admission, the resident had multiple diagnoses including type 2 diabetes mellitus, acute pain due to trauma, bilateral above-knee amputations, adult failure to thrive, stage III pressure ulcer of the sacral region, and peripheral vascular disease. Despite having an active order for wound treatment and dressing, there was no order or implementation of Enhanced Barrier Precautions (EBP) as required for residents with such wounds. The resident's baseline care plan was not completed, and the comprehensive care plan did not include EBP interventions. Observations revealed the absence of a PPE bin and signage outside the resident's room, and staff, including the ADON, provided wound care using gloves but not gowns. Interviews with staff indicated a lack of awareness and adherence to EBP protocols, despite documented training on infection control and EBP. The ADON, who performed wound care, acknowledged not using proper PPE and stated that the absence of signage contributed to this oversight. The infection control preventionist confirmed that EBP was necessary for the resident and that staff had been trained on the requirements. Facility policy required EBP for residents with wounds to reduce the transmission of multi-drug-resistant organisms, but this was not followed in the resident's care.
Failure to Ensure Appropriate Wheelchair Assessment and Maintenance for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and equipment to maintain or improve mobility with maximum practicable independence, unless a reduction in mobility was unavoidable. The resident in question had significant medical conditions, including morbid obesity, muscle weakness, and difficulty walking, and relied on a motorized wheelchair (MWC) for mobility. Despite documented weights consistently above 550 pounds, there was confusion and lack of verification regarding the wheelchair's weight capacity, with conflicting information from various sources and no clear documentation or assessment by facility staff to confirm the suitability of the equipment. Multiple interviews revealed that the resident experienced repeated mechanical issues with the MWC, including broken and bent casters, which led to reduced use of the wheelchair due to safety concerns. The facility staff, including the Director of Rehabilitation (DOR), Director of Nursing (DON), and Administrator (ADM), were aware of the equipment issues but did not take timely or coordinated action to assess the wheelchair's appropriateness or arrange for necessary repairs. The facility's therapy and nursing staff did not refer the resident for a wheelchair evaluation, and there was a lack of communication and follow-through regarding responsibility for repairs and equipment replacement, despite clear indications from the resident's insurance that the facility was responsible for durable medical equipment (DME) while the resident remained in the facility. Documentation and interviews further indicated that the facility did not obtain or review the wheelchair's specifications or owner's manual to verify its weight capacity, nor did they maintain records of repairs or ensure that the resident's needs were being met. The resident, feeling unsafe and unsupported, attempted to resolve the issues independently and through external vendors, but encountered barriers due to outstanding balances and vendor policies. The facility's failure to assess, document, and provide appropriate equipment and services resulted in the resident being at risk of unsafe mobility and not receiving care to maintain or improve range of motion and independence.
Failure to Maintain Bed in Lowest Position and Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
Nursing staff failed to ensure that a resident with severe cognitive impairment and a history of falls received adequate supervision and assistive devices to prevent accidents. The resident, diagnosed with neurocognitive disorder with Lewy bodies, psychotic disorder, generalized anxiety disorder, and severe dementia with behavioral disturbances, was observed lying in bed with the head elevated and the bed positioned approximately 3.5 feet off the floor. The care plan for this resident required the bed to be kept in the lowest position with brakes locked and frequent observation, as well as placement in a supervised area when out of bed. However, during observation, the resident was left unsupervised, moving and reaching for blankets on the floor, with no staff in the immediate vicinity. A CNA later confirmed that she had transferred the resident to bed 15-20 minutes prior and admitted to forgetting to lower the bed to its lowest position, despite knowing the resident was a fall risk and had a history of attempting to get out of bed without assistance. The DON also acknowledged that the resident was impulsive, unsteady, and required the bed to be in the lowest position to prevent falls. Facility policy on fall risk management specifically identified incorrect bed height as an environmental risk factor for falls. No falls were recorded for the resident during the review period, but the failure to follow care plan interventions and provide adequate supervision constituted a deficiency.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Specifically, residents on the 300/400 hallway were provided showers in a room that was not free of potentially infectious debris. Observations and interviews revealed that soiled briefs, linens, and dirty towels were left on the floor and shower chair in the shower room after use. One resident reported encountering these items upon entering the shower room, and another resident confirmed seeing dirty towels on the floor on different occasions. Photographic evidence of the soiled items was presented to facility leadership, who initially expressed disbelief but later acknowledged the issue. Housekeeping staff stated that they were responsible for cleaning the shower after each use and recognized the risk of infection transmission if soiled items were handled without gloves. Additionally, the facility failed to ensure that two residents were properly screened for tuberculosis (TB) prior to or upon admission and annually, as required by facility policy. Record reviews showed that one resident had no documentation of TB screening at admission or within the past year, and another resident, while screened at admission, had not received annual TB screening. The facility's policy mandates TB screening for all admissions and annual follow-up, but this was not consistently implemented. The residents involved had complex medical histories, including diagnoses such as Alzheimer's disease, pressure ulcers, osteomyelitis, respiratory failure, and other chronic conditions. Some residents were cognitively impaired, while others were cognitively intact. The failure to maintain a sanitary shower environment and to conduct required TB screenings directly contravened the facility's own infection control and TB screening policies, as confirmed by record reviews and staff interviews.
Failure to Provide Bariatric Bed and Trapeze for Resident Needing Accommodation
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident with significant medical needs, specifically by not ensuring the resident had the appropriate bariatric bed and overhead trapeze as recommended by the therapy department and ordered by the physician. The resident, who had a BMI over 70, morbid obesity, muscle weakness, and other complex medical conditions, required a 60-inch-wide bariatric bed and an overhead trapeze to facilitate self-positioning, self-transfer, and bed safety. Despite therapy and physician orders dating back to August, the resident continued to use a 48-inch-wide bed without a trapeze as of November, making it difficult for him to reposition and transfer independently. Interviews and record reviews revealed that the therapy department and physician had communicated the need for the equipment to the Administrator, DON, and Corporate RVP, but there was no evidence that the equipment was ordered or purchased in a timely manner. The Administrator stated she had placed the order as soon as she became aware, but could not provide a purchase order or delivery timeline. The DON was unable to explain the delay or provide documentation confirming the purchase, and conflicting statements were made regarding when staff were notified of the need. Facility policy confirmed the resident's right to reasonable accommodation, but the necessary adaptive equipment was not provided as required.
Failure to Ensure 24-Hour Visitation Access
Penalty
Summary
The facility failed to ensure that residents had unrestricted access to visitors of their choosing at any time, as required by federal and state regulations and the facility's own policies. Specifically, one resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's Disease, vascular dementia, and major depressive disorder, was unable to receive visitors after 8:00PM because the front door was locked and staff did not respond to the doorbell. The resident's POA reported having to arrive before 8:00PM to visit and stated that repeated requests to facility leadership to address the issue were unsuccessful. The POA also attempted to alert staff through an electronic surveillance device in the resident's room, but staff did not respond to the front door. Interviews with the DON and Administrator revealed confusion and lack of implementation regarding after-hours visitor access. Although discussions had occurred about possible solutions, such as posting an on-call phone number or assigning a charge nurse to answer the door, no measures had been put into practice. Facility policies reviewed confirmed that residents are entitled to 24-hour visitation access, but these policies were not followed in practice, resulting in the resident's inability to receive visitors after regular hours.
Failure to Provide Reasonable Telephone Access and Privacy
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of telephones, as required by resident rights policies. Two residents were specifically affected: one resident, who was cognitively intact but had significant visual impairment, possessed a personal cell phone but was unable to use it effectively due to her declining vision. Her emergency contact reported frequent difficulties reaching her through the facility, as calls to the facility phone were rarely answered. The activities director indicated that a cordless phone was available for residents on her hallway, but this was not accessible to her. Another cognitively intact resident did not have a personal cell phone and relied on the facility-provided cordless phone, which was found to be non-operational. She reported repeated requests to nursing staff about the phone, being told it needed charging or was not working. Observation confirmed the phone was unplugged and the wiring was pushed into a hole in the wall. The DON initially claimed the phone was functional but, upon inspection, acknowledged the issue and deferred to maintenance, who confirmed the phone had not worked for an undetermined period. There was no alternative provided for bedbound residents to access a phone if they did not have a personal device. Interviews with facility leadership revealed a lack of clear procedures for family access to the building and for ensuring residents could communicate with individuals outside the facility, especially after business hours. The facility's own policy required access to a telephone and privacy for communication, but these requirements were not met for the affected residents, as evidenced by the inoperable phone and lack of alternative arrangements.
Failure to Enforce Smoking Safety Policy and Supervision
Penalty
Summary
A deficiency occurred when a resident, who was assessed as a safe smoker and was cognitively intact, was found to have cigarettes and a lighter in her personal possession in her room, contrary to facility policy. The resident, who had diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, and neuropathies, was fully ambulatory and required supervision to no assistance with activities of daily living. Her care plan specified that she should not keep cigarettes or a lighter in her room and that these items should be stored safely, with smoking to be supervised as needed. Despite these care plan interventions and the facility's smoking policy, which prohibits residents from keeping smoking articles in their rooms and requires all smoking to be supervised with items stored in a lock box, the resident stated she was allowed to keep her cigarettes and lighter because she was a safe smoker. She also reported that she did not have to follow the policy due to her status. Staff interviews revealed confusion and inconsistency regarding the enforcement of the smoking policy, with the DON stating the resident was allowed to smoke unsupervised, while the Corporate RVP confirmed that all residents should be supervised and not keep smoking articles in their rooms. Further review of facility documentation showed that the required documentation sheet for tracking cigarettes and lighters had not been filled out for the past 30 days, and some staff were unaware of the documentation process. The facility's smoking policy and in-service records clearly outlined the procedures for supervised smoking and the handling of smoking materials, but these were not consistently followed, leading to the deficiency.
Failure to Provide Prescribed Therapeutic Diet and Adequate Portions
Penalty
Summary
The facility failed to provide a resident with a nourishing, palatable, well-balanced diet that met the resident's daily nutritional and special dietary needs, as prescribed by the physician. The resident, a male with multiple diagnoses including morbid obesity, acute respiratory failure, and various mental health conditions, was cognitively intact and had specific dietary orders for a regular diet with double portions of protein at all meals and double portions of vegetables at lunch and dinner. Despite these orders, multiple instances were documented where the resident did not receive the prescribed portions or appropriate food substitutions, as evidenced by photos of meal trays and tray tickets provided by the resident and reviewed by the Ombudsman and surveyors. Interviews with facility staff, including the Dietary Manager, Administrator, and DON, revealed a lack of clarity regarding what constituted a vegetable, with staff acknowledging that items like French fries and mashed potatoes were not considered vegetables. The Dietary Manager reported that recent budget cuts by the new management company limited the ability to purchase fresh food and provide alternative meal choices, resulting in insufficient food to meet double portion requirements. The kitchen inventory confirmed a limited supply of fresh and frozen vegetables, and the Dietary Manager stated she was only allowed to prepare food for the exact number of residents, not accounting for second helpings or special dietary orders. Facility policy required that all therapeutic diets be served according to physician orders, with substitutions made for allergies and preferences as reviewed by the registered dietician. However, the facility's food master list did not specify which foods were considered vegetables, and the registered dietician was unavailable for comment. The resident expressed concerns about not receiving full meals and attributed the issue to budget constraints and management decisions, which was corroborated by staff interviews and observations.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided consent prior to the administration of a psychotropic medication. Specifically, for a female resident with diagnoses including Type 2 Diabetes Mellitus, Paranoid Schizophrenia, and Celiac Disease, there was no documented informed consent for the use of Olanzapine, an antipsychotic medication, in the resident's medical record. The resident had severe cognitive impairment as indicated by a BIMS score of 6, and her care plan included the use of antipsychotic medication with related interventions. Despite an order for Olanzapine and ongoing care, the required consent form was not present in the electronic medical record, and staff were noted to be awaiting the consent form from the contracted psychiatry agency. Interviews with facility staff revealed a lack of clear responsibility for obtaining psychotropic medication consents, with both nursing staff and the social worker sometimes involved. The DON and Administrator both acknowledged the importance of obtaining consent quickly, but there was no specific staff member assigned to this task. The facility's policy states that residents have the right to receive information about psychoactive medications and to refuse consent, but this process was not followed for the resident in question, as evidenced by the missing consent documentation for Olanzapine.
Call Light Not Accessible to Resident with Severe Cognitive Impairment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical assistance needs was found lying in bed with her call light on the floor, out of her view and reach. The resident's medical history included catatonic disorder, a parathyroid gland neoplasm, and sick sinus syndrome. Her care plan specifically identified her as being at risk for falls due to impaired cognition, mobility, and lack of safety awareness, and directed that the call light be kept within reach. Observation confirmed the call light was not accessible to the resident, and staff interviews acknowledged the issue, with an LVN noting the resident was unable to call for help. The facility's policy required call lights to be positioned conveniently for residents, but this was not followed in this instance.
Failure to Label and Discard Enteral Feeding Containers
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a feeding tube received appropriate treatment and services to prevent complications. Specifically, the feeding formula and water containers used for a resident with a gastrostomy tube were not labeled with the required identifiers, such as the resident's name, date, and time of infusion. Observations showed that the containers remained hanging from the feeding pole after the feeding was completed, and the feeding pump was turned off. Staff interviews confirmed that the containers were supposed to be labeled to ensure correct administration and to track how long the formula had been in use, but this was not done. Additionally, staff indicated uncertainty about the time frame for the resident's nocturnal feedings and whether the remaining formula and water could be reused. The resident involved was a female with a history of cerebral infarct, aphasia, dysphagia, gastro-esophageal reflux, and gastrostomy status, and was assessed as severely cognitively impaired. Physician orders specified the administration of enteral feedings and water flushes at set times and rates. Facility policy required that all feeding equipment be labeled and changed according to specific guidelines, but these procedures were not followed. The Director of Nursing acknowledged that the formula should be labeled and discarded after 24 hours, and failure to do so could result in the use of outdated formula.
Failure to Document and Notify Resident of Discharge and Appeal Rights
Penalty
Summary
The facility failed to ensure proper documentation and notification during the discharge process of a resident who was sent to the hospital for a change in condition and subsequently not readmitted. The resident, who was cognitively intact and had complex medical needs including a stage 4 pressure ulcer, neurogenic bladder and bowel, and quadriplegia, was discharged without a 30-day discharge notice, discharge orders, or a discharge summary present in the electronic medical record (EMR) at the time of review. The facility only provided a discharge order and summary after the surveyor requested it, and these documents were dated several weeks after the actual discharge event. Interviews with facility staff revealed that the decision not to readmit the resident was based on concerns about non-compliance with care, suspected drug use, and perceived safety risks to other residents. The administrator, DON, and social worker all supported the decision not to allow the resident to return, citing issues such as missed wound care appointments, non-compliance with repositioning, and reports of drug use and paraphernalia. However, the physician was not aware of the discharge at the time it occurred, and the DON admitted to not realizing that proper discharge documentation had not been completed. The facility's own policy required that residents and/or responsible parties be notified prior to transfer or discharge, and that discharge documentation, including physician orders and a discharge summary, be present in the clinical software. These requirements were not met in this case, as there was no evidence of a 30-day discharge notice or timely discharge documentation in the resident's EMR. The lack of proper documentation and notification could affect residents who are sent to the hospital for a change in condition and are not readmitted.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the administrator and to the State Survey Agency, as required by regulation and facility policy. Specifically, two residents made allegations of abuse on the same day, but these were not reported to the appropriate authorities. The first resident, who had a history of paranoid schizophrenia and a BIMS score indicating intact cognition, reported being fondled by a male resident. The incident was documented in the LVN's progress notes, and the DON was informed and spoke with the resident, but the allegation was not reported to the state or further investigated as required. The second resident, who had severe cognitive impairment due to vascular dementia, reported being hit by a female resident. This allegation was also documented in the progress notes, and the resident was subsequently moved to another unit. However, the DON stated she was not aware of this allegation until the survey, and the administrator acknowledged seeing the nursing note but did not receive a direct report. Neither of these incidents was reported to the state agency, as confirmed by a review of the TULIP reporting system. Interviews with facility staff revealed confusion and inconsistency regarding the criteria for reporting abuse allegations. The DON indicated that the resident's BIMS score influenced her decision not to report, and the administrator cited a lack of eyewitnesses and the residents' histories of making unsubstantiated claims as reasons for not reporting. The facility's own policy requires immediate reporting of all allegations or suspicions of abuse, regardless of perceived credibility or witness presence, but this protocol was not followed in these cases.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of abuse and mistreatment involving two residents. In the first incident, a resident with a history of psychiatric diagnoses and a BIMS score indicating intact cognition reported being fondled by a male resident. The LVN documented the resident's distress and her statement about being touched, and the DON was notified. However, the DON did not believe the allegation was reportable, citing the resident's cognitive status and the lack of direct disclosure during her own interaction with the resident. The administrator was aware of the allegation but did not interview the resident or initiate a formal investigation, referencing the resident's history of making unsubstantiated claims and the absence of witnesses. In the second incident, another resident with severe cognitive impairment and behavioral disturbances reported being hit by a female resident. The LVN documented the statement and observed the resident's agitation, but the DON was not made aware of the allegation and only learned of it during the survey. The administrator acknowledged seeing the nursing note but did not receive a formal report or initiate an investigation, as the resident could not recall the event and there were no witnesses. The LVN noted that the resident was moved to another unit following the incident, but no further documentation or investigation was completed. Interviews with facility staff revealed inconsistent responses to the allegations, with reliance on residents' cognitive status and the presence of witnesses as determining factors for reporting and investigating abuse. The facility's policy requires all allegations of abuse, neglect, or mistreatment to be promptly reported and thoroughly investigated, regardless of the circumstances. The failure to follow these protocols resulted in a lack of comprehensive investigation and documentation for both incidents, as required by facility policy and state regulations.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, as observed during a survey. A pile of yellow liquid, identified as urine, was found on the restroom floor of the resident's room. This observation was made during a visit, and the floor was noted to be sticky with a foul odor present in the room. The presence of urine on the floor poses a risk of falls, as confirmed by an interview with an LVN who acknowledged that a resident could slip, fall, and potentially sustain a fracture. The resident involved had multiple diagnoses, including depression, anxiety, tremor, lack of coordination, type 2 diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary disease, cognitive communication deficit, unsteadiness on feet, paranoid schizophrenia, seizures, and abnormalities of gait and mobility. The resident's care plan indicated functional bowel/bladder incontinence and a risk for falling due to an unsteady gait. The care plan included approaches such as frequent checks and assistance with toileting, ensuring the floor is free of liquids, and performing frequent housekeeping rounds. Despite these measures, the facility did not maintain the environment as required, leading to the deficiency.
Unattended and Unlocked Medication Cart Found in Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During an observation, a medication cart located near the nurses' station was found unattended and unlocked, with medication blister packs inside. The lock button on the cart was unengaged, leaving the medications unsecured. This incident involved Medication Cart 2, which was not assigned to any staff member at the time of the observation. Interviews with staff revealed a lack of awareness and responsibility regarding the unlocked medication cart. LVN A, who was not assigned to the cart, acknowledged that it should have been locked and was unaware of its contents. The Director of Nursing (DON) confirmed that the cart was being used for medication storage and was not aware of when it was last accessed by staff. The facility's policy mandates that medications be stored securely to prevent tampering or misuse, which was not adhered to in this instance.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to employ a certified dietary manager as required, which could place residents at increased risk of foodborne illness and inadequate nutrition. The deficiency was identified during an interview and record review, revealing that the facility's dietary manager had not completed the necessary certification course. The dietary manager, hired on 06/17/21, was unaware of the requirement to complete a certified dietary manager course. This was her first position as a dietary manager, and her previous experience was limited to working as a cook. Interviews with the Human Resources Director and the Administrator further highlighted the oversight. The Human Resources Director admitted she was unaware of the certification requirement and acknowledged that she and the Administrator were responsible for ensuring department heads met their certification requirements. The Administrator also stated he was not aware of the certification requirement and agreed that completing the course would help the dietary manager run the kitchen more effectively. The facility's employee handbook, dated 81/21, mandates that all professionally registered, licensed, and certified staff maintain current licensure, registration, and/or certification.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. Several items in the refrigerator, including a plastic bag of cheese, a plastic bag of beets, and a one-gallon plastic container of pudding, were not labeled or dated. This lack of labeling and dating could lead to the inability to determine the expiration dates of these food items, posing a risk of foodborne illness to residents. Additionally, the temperature gauge on the dish machine in the dish room was not functioning, which is crucial for ensuring proper sanitation. Interviews with the Dietary Manager revealed that the temperature gauge had been non-functional for about a month, and although the issue had been reported to the Maintenance Director and the dish machine service representative, no work order was found in the facility's Maintenance Log Book for the repair. The Dietary Manager also confirmed that food in the refrigerators must be dated and labeled, and acknowledged the importance of a working temperature gauge for sanitation purposes. Further observations and interviews highlighted issues with the distribution and labeling of snacks in the Nourishment Rooms. Snacks were not consistently labeled or dated, and there was a lack of cleaning in the refrigerators, with a build-up of ice and spilled liquids observed. The DON and Dietary Manager acknowledged these issues, noting that snacks should be labeled with the date and time they were brought out to ensure they are safe to eat. The facility's policies on food storage and kitchen safety were not being followed, contributing to these deficiencies.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During an observation, several deficiencies were noted, including a disconnected bathroom ceiling fan, a broken bedroom light fixture, broken window shade vents, a wall penetration, a missing ceiling panel, water discoloration marks around a ceiling vent, missing floor molding, and non-working light bulbs in a hallway ceiling light unit. These issues were identified in various resident rooms and corridors, indicating a lack of proper maintenance and oversight. Interviews with the Administrator revealed that the Maintenance Director had recently self-terminated, and there was no facility policy on preventative maintenance. The Maintenance Director had maintained a work order communication log, but a review of the facility's Maintenance Log Book showed no recorded work orders for the identified issues over the previous months. The Administrator acknowledged that these deficiencies could negatively impact resident safety and satisfaction.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous gnats in a resident room and numerous flies on the 200 hall. Additionally, a cockroach was observed in the conference room. These observations were made during a survey conducted on June 4 and June 5, 2024. The facility had a contract with a pest control company, which had serviced the facility twice in May 2024 to treat for ants and insects. However, the maintenance person responsible for overseeing the pest control program had quit on June 4, 2024, leaving the facility without proper oversight for pest management. The administrator acknowledged the issue and stated that the maintenance supervisor from a sister facility was temporarily handling pest control duties.
Failure to Document Anticoagulant Use in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not address the resident's use of anti-coagulant medication, Eliquis, which was prescribed to the resident starting on February 6, 2024. This omission was identified during a review of the resident's care plan, which was initiated on the same date as the medication start date, but failed to document the anti-coagulant medication use. Interviews with the Director of Nurses and the MDS LVN-A confirmed that the resident's anti-coagulant medication use was not documented in the current care plan. Both staff members acknowledged the importance of including medication usage in the care plan for treatment monitoring purposes. The facility's policy, dated December 2017, requires staff to develop a comprehensive care plan with measurable and time-limited goals to meet the needs of the resident, which was not adhered to in this case.
Inadequate Supervision During Mealtimes
Penalty
Summary
The facility failed to ensure adequate supervision for a resident during mealtimes, which led to a deficiency in care. The resident, a male with a history of seizures, cerebrovascular disease, and severe impairments in daily decision-making, was on a mechanically altered diet and required supervision during meals to prevent choking or aspiration. Despite these needs, the resident was observed eating alone in his room without the necessary adaptive equipment, such as a divided plate, and was not provided with the required supervision. This lack of supervision and appropriate equipment increased the risk of choking and aspiration for the resident. The resident's care plan and physician orders indicated the need for specific dietary modifications and supervision during meals. However, observations revealed that the resident was served meals that did not comply with these orders, including hard toast and a regular plate instead of a divided one. Additionally, the resident was left unsupervised, which contradicted the recommendations from the speech therapist, who had advised that the resident should eat in the dining room with staff supervision due to his inability to communicate effectively and the risk of emergency events if he were to choke or aspirate. Interviews with facility staff, including the Dietary Manager, Speech Therapist, and Director of Nursing, highlighted communication gaps and a lack of adherence to the resident's care plan. The Dietary Manager was unaware of the resident's food allergies, and the Speech Therapist's recommendations for supervision were not consistently implemented. The Director of Nursing acknowledged that the resident was supposed to be supervised during meals but did not document or care plan the resident's refusals to eat in the dining room. These oversights contributed to the deficiency in providing adequate supervision and care for the resident during mealtimes.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for several residents, as evidenced by multiple observations and interviews. Resident #2's bathroom had a black substance caked over the interior of the toilet bowl, and the air conditioning unit was covered in dust. Despite daily cleaning by housekeeping staff, the issue persisted, and the housekeeper acknowledged the need for additional materials to clean the toilet. The Maintenance Director was aware of the problem but had not provided the necessary resources to address it. Resident #3's room had peeling drywall on the wall behind the bed, which the Maintenance Director was aware of but had not yet addressed. This lack of maintenance contributed to an environment that was not homelike or comfortable for the resident. The Maintenance Director admitted that such conditions would be upsetting if his family were living in a similar facility. Resident #6 reported that her room had not been cleaned properly, with dirty mop water used and areas like the closet floor and behind a storage container left uncleaned. Resident #7's room was observed to have various debris and substances on the floor, and the resident expressed discomfort with the uncleanliness. The Maintenance Supervisor and Housekeeper B acknowledged the need for better cleaning practices but had not yet implemented them effectively.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in meeting their needs. For one resident, who had a history of seizures, cerebrovascular disease, and severe impairments in daily decision-making, the facility did not adequately address his refusal to eat in the dining room. Despite recommendations from the Speech Therapist for the resident to eat in the dining room for supervision due to his dysphagia and risk of choking, the resident was observed eating alone in his room with inappropriate meal setups, such as a regular plate instead of a divided plate, and without necessary adaptive equipment like lids and straws. The resident's care plan did not document his refusals to eat in the dining room, and staff did not consistently supervise him during meals, contrary to the Speech Therapist's recommendations. Another resident, who had a history of cerebral infarction, Alzheimer's disease, and falls, was not properly care planned for the use or refusal of fall mats. The resident was observed with a fall mat folded and not covering the side of the bed, which was not addressed in her care plan. The Director of Nursing acknowledged that the resident had memory issues and would often kick the fall mats out of the way, but this was not documented or care planned. The lack of a comprehensive care plan for the resident's fall risk and the improper use of fall mats could potentially place the resident at risk of injury. The facility's failure to develop and implement comprehensive care plans for these residents highlights a lack of coordination and communication among staff regarding the residents' needs and interventions. The Speech Therapist's recommendations were not effectively communicated or incorporated into the care plans, and the Director of Nursing was not fully aware of the residents' needs and the necessary interventions. This lack of comprehensive care planning could lead to unmet needs and potential risks for the residents.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, specifically in the case of a resident's medication storage. During an observation, it was noted that a resident had a furosemide pill left unattended on their bedside table. The resident, who was cognitively intact but had severely impaired vision, identified the pill and took it without supervision. The medication was left by a male nurse who had given it to the resident earlier but did not ensure it was taken or properly stored. The nurse admitted to leaving the medication at the bedside, acknowledging that it was against protocol as it could lead to medication misuse or loss. The Director of Nursing confirmed that medications should not be left unattended to prevent unauthorized access or potential health risks. The facility's policy stated that only authorized personnel should have access to medications, highlighting a breach in procedure that could affect the resident's health and safety.
Failure to Provide Properly Prepared Meals for Resident on Mechanical Soft Diet
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident who was on a mechanically altered diet. The resident, who had a history of seizures, cerebrovascular disease, and severe impairment in daily decision-making, was observed being served a hard piece of toast, which was inappropriate for his mechanical soft diet. The resident attempted to eat the toast, resulting in a crunch noise, indicating the bread was too hard for him to consume safely. Additionally, the resident was seen eating spaghetti with his hands due to difficulty using a fork, and his meal tray lacked necessary items such as straws, condiments, and cheesecake. The dietary manager acknowledged that the bread was overcooked and unsuitable for residents on a mechanical soft diet. The manager also noted that the gelatin snack provided was not prepared correctly, being too watery. These observations and interviews highlight the facility's failure to ensure that the resident received meals in the proper consistency, which could lead to dissatisfaction, poor intake, choking, and weight loss.
Failure to Document and Communicate Resident's Food Allergy
Penalty
Summary
The facility failed to accommodate a resident's food allergy to mushrooms, as observed during a survey. The resident, a male with multiple medical conditions including seizures, cerebrovascular disease, and hemiplegia, was noted to have an allergy to mushrooms documented on his face sheet. However, during an observation, the resident's dietary form accompanying his meal tray did not list any allergies, indicating a failure to communicate this critical information to the dietary staff. Interviews with the Dietary Manager (DM) revealed that there was no record of the resident's mushroom allergy in the dietary binder, and the DM was unaware of the allergy. The DM stated that the kitchen did not have mushrooms at the time, but the lack of documentation posed a risk of exposure. The Director of Nursing (DON) acknowledged uncertainty about the severity of the allergy but emphasized the potential for a severe allergic reaction. The facility's policy on nutritional recommendations outlined procedures for addressing dietary needs, but these were not followed in this instance, leading to the deficiency.
Failure to Provide Adequate Hydration Support
Penalty
Summary
The facility failed to provide drinks consistent with the needs and preferences of a resident during meal service, specifically failing to provide water during lunch on a specified date. The resident, a male with a history of seizures, cerebrovascular disease, and other significant health issues, was observed with a coffee cup and a clear cup with a purple liquid, both without lids, and no straws were provided. The tray had liquid spilled all over it, and the resident's hand was shaking, indicating difficulty in managing the drinks provided. The resident's care plan required set-up assistance for eating and drinking, and he was on a mechanically altered diet with thin fluids. The speech therapist had evaluated the resident in March and noted that due to his history of stroke and dysphagia, he should have a divided plate with meals and cups with plastic lids and straws. However, during the observation, these recommendations were not fully implemented, as evidenced by the lack of lids and straws. The facility's policy on nutritional recommendations outlines a process for addressing dietitian recommendations, but it appears that the necessary adjustments for this resident's meal service were not adequately followed, leading to the deficiency.
Failure to Provide Special Eating Equipment for Resident
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required them, specifically a divided plate, which was necessary for the resident's assistance with eating. This deficiency was observed during meal times when the resident was served meals on a regular plate instead of the prescribed divided plate. The resident, who had a history of stroke and was diagnosed with conditions such as seizures, cerebrovascular disease, and hemiplegia, was dependent on assistance for activities of daily living, including eating and drinking. The resident's care plan and physician orders clearly indicated the need for a divided plate and other adaptive equipment to aid in meal consumption. During observations, it was noted that the resident struggled to eat using a regular plate, resulting in food spillage and the resident resorting to eating with his hands. The dietary staff failed to adhere to the diet sheet instructions, which specified the use of a divided plate for the resident. Interviews with the Dietary Manager and Speech Therapist confirmed the oversight, with the Dietary Manager acknowledging the availability of divided plates and the need for staff to follow the diet sheet instructions. The Speech Therapist also emphasized the importance of the divided plate and additional adaptive equipment, such as cups with lids and straws, to assist the resident due to his dysphagia and preference for eating with his hands. The facility's policy on nutritional recommendations outlined the process for addressing dietary needs and recommendations, including the use of adaptive equipment. However, the failure to provide the necessary equipment as per the resident's care plan and physician orders indicates a lapse in following these procedures. This oversight could potentially impact the resident's ability to consume meals effectively, leading to issues such as weight loss and diminished independence.
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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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