Parklane West Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 2 Towers Park Ln, San Antonio, Texas 78209
- CMS Provider Number
- 675509
- Inspections on file
- 49
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Parklane West Healthcare Center during CMS and state inspections, most recent first.
Two residents with multiple chronic conditions, including HTN, COPD, pneumonitis, and prior cerebral infarction, had their BP taken by a medication aide using the same blood pressure cuff without disinfection between uses. The aide placed the cuff on the med cart after each use and did not clean it, despite facility policy requiring common-use equipment to be cleaned and disinfected before use on another resident. In interview, the aide reported being focused on giving meds on time and lacking sanitizing wipes on the cart, and acknowledged understanding that bacteria on the cuff could be transferred between residents. Facility leadership stated that staff are expected to restock and use sanitizing wipes and that failure to sanitize the cuff places residents at risk for infection.
A deficiency occurred when the facility failed to ensure hot water was available in resident rooms for showers, preventing a warm and comfortable bathing experience for multiple residents. One cognitively impaired resident, fully dependent for personal care, had no documented showers or baths for an extended period despite a scheduled bathing routine, and her family had filed a grievance about the lack of hot water. Two cognitively intact male residents, one with paraplegia and one with cirrhosis and diabetes, reported that their room showers had only cold or lukewarm water for weeks; they often refused showers when hot water could not be found, sometimes accepting sponge or bed baths instead, and one refused to bathe in other residents’ rooms. Staff and the Maintenance Director confirmed ongoing hot water problems on one wing, acknowledged that management was aware, and described workarounds such as using other rooms with hot water, obtaining hot water from common areas, or pouring basins of hot water over residents in their own showers, which did not consistently meet the facility’s policy to provide comfortably tempered shower water.
The facility failed to maintain safe and consistent hot water temperatures in resident rooms on two floors, with surveyor measurements showing some showers and sinks at 118°F and others as low as the upper 70s to low 90s. Staff interviews revealed that CNAs were informally instructed by an LVN to use basins to mix water or to find alternative rooms when water was too hot or too cold, and that maintenance concerns were often reported verbally rather than through the required system. The Maintenance Director and Administrator acknowledged that fluctuating water temperatures had been an ongoing issue for months, that there was no clear knowledge of the required temperature range, and that there was no facility policy governing water temperatures or the physical environment, while leadership and maintenance staff agreed that failure to maintain proper temperatures could result in scalding or other physical injuries.
Surveyors found that two residents did not have comprehensive, person-centered ADL care plans consistent with their MDS assessments and documented care needs. One cognitively impaired resident with a history of stroke and vascular dementia required maximal assistance with bathing and total dependence for personal hygiene/toileting, yet her care plan listed shower/baths as not applicable. Another cognitively intact resident with paraplegia and diabetes required maximal assistance or total dependence for multiple ADLs, but his care plan only stated he should be encouraged to participate, without specifying his actual ADL requirements. The new, inexperienced MDS Coordinator, who was focused on skilled rather than LTC residents, and the DON acknowledged that the care plans were incomplete and did not reflect the residents’ assessed needs, despite a facility policy requiring comprehensive person-centered care plans with measurable objectives and timeframes.
A resident with a history of stroke, vascular dementia, and dependence on staff for bathing and personal hygiene had no showers, baths, or sponge baths documented in the medical record over a reviewed 30-day period, despite shower sheets showing multiple showers and a bed bath were provided on scheduled days. The DON reported uncertainty about whether shower sheets were part of the medical record and indicated that Medical Records handled uploads, while Medical Records staff stated they did not upload shower sheets and kept them only for internal use. This practice conflicted with facility policy, which required Nursing Assistants ADL Flow Sheets as part of the medical record, resulting in incomplete and inaccurate documentation of the resident’s ADL care.
The facility failed to maintain safe and consistent hot water temperatures in several resident rooms, with water in some sinks measuring well below 100°F and in one room measuring 118°F. A resident with intact cognition reported being instructed to use wipes or hand sanitizer when the water was not hot enough, while another resident’s representative stated that staff had to obtain hot water from another location to provide bed baths. Involved residents had conditions including dementia, cognitive communication deficits, weakness, and sepsis. Staff interviews revealed that the hot water issues began after utility work at a connected facility, resulting in intermittent hot water problems over several weeks, and that residents were informed when their hot water was not working and were offered alternative means for hand hygiene. The facility did not have a policy specific to water temperatures, relying instead on a general environmental safety policy.
Two residents with severe cognitive impairment and multiple chronic conditions repeatedly received their scheduled morning medications several hours late. Over multiple days, a medication aide administered numerous 7:00 AM medications, including anticoagulants, antihypertensives, seizure medication, diuretics, antidepressants, supplements, and topical analgesics, between approximately 10:00 AM and 10:57 AM. The aide reported attempting to work around therapy sessions and appointments, while the DON noted that therapy and family visits could affect timing. The interim ADM stated there was no formal policy defining exact administration time frames, and staff relied on a reference sheet listing broad day-shift medication windows. Surveyors determined the facility failed to ensure accurate and timely medication administration for these residents.
A resident with severe cognitive impairment and legal blindness was observed in a hallway with a Foley catheter bag attached to his calf, visibly filled with urine and lacking a privacy cover, despite care plan orders and facility policy requiring its use. Staff interviews revealed confusion about responsibility for ensuring privacy covers, and the assigned LVN admitted not placing a cover during his shift, even though supplies and training were available.
The facility did not consistently document the completion of daily wound care treatments for three residents with complex medical needs, including diabetes, pressure ulcers, and amputations. Treatment administration records were left incomplete on multiple occasions, and staff interviews revealed that missing documentation could be due to various reasons, including possible EMR issues or failure to perform or record the treatments. The absence of proper documentation meant there was no reliable way to confirm whether the required wound care was provided as ordered.
A medication cart on Hall A was found unattended and not properly locked, with drawers containing medications accessible despite the locking mechanism being engaged. An LVN confirmed the cart was not secured and acknowledged responsibility for its security. Interviews with the ADON and DON confirmed that only authorized staff should have access to medications and that the cart should be locked or attended at all times, as required by facility policy.
A resident was not assessed completely and in a timely manner upon admission and at the required 12-month interval, as mandated. This resulted in noncompliance with required assessment protocols.
A plan to meet a resident's most immediate needs within 48 hours of admission was not created or put into place, as required. The facility did not ensure that a process was followed to assess and address the immediate needs of newly admitted residents within the specified timeframe.
A resident with an indwelling catheter did not receive proper catheter care when a CNA failed to clean the catheter tubing during incontinent care and did not ensure the catheter was secured with a leg strap as ordered. The CNA acknowledged not following correct procedures due to distractions, and facility records confirmed the requirement for both cleaning the catheter and securing it with a leg strap.
A resident with multiple health conditions and at risk for pressure ulcers did not have required weekly skin assessments documented for two weeks. Review of the EMR and progress notes confirmed the absence of these assessments, and staff interviews indicated that both floor nurses and the treatment nurse were responsible for this documentation. The facility's policy required weekly skin checks and documentation, which was not followed in this instance.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Three residents experienced unsafe and uncomfortable conditions due to a broken shower handle and a rusty, peeling toileting chair. Two residents had to use a shower in another room for weeks because their own bathroom's shower handle was missing, despite multiple work orders. Another resident was given a rusty toileting chair that caused discomfort and concern, and no work order was submitted for its repair or replacement. The facility lacked a maintenance director, leading to unresolved maintenance issues and failure to maintain equipment as required by policy.
Three residents with documented mental illness diagnoses, including major depressive disorder, schizoaffective disorder, and bipolar disorder, were not properly identified as having a mental illness on their PASRR Level I screenings. Despite clear evidence in medical records, MDS assessments, and medication orders, the PASRR forms indicated 'No' for mental illness, and staff interviews revealed a lack of understanding about correct PASRR procedures.
The facility did not ensure that care plans were comprehensive and up-to-date for several residents, omitting key diagnoses such as allergies, constipation, and the presence of a nephrostomy tube, and failing to update care plans after the removal of a catheter or the initiation of a WanderGuard device. These omissions were confirmed through record review, observation, and staff interviews, and were not in accordance with facility policy requiring person-centered care plans with measurable objectives.
Surveyors identified several deficiencies in food service safety and sanitation, including undated food items in storage, lack of a garbage bin under the hand sink, non-functioning overhead lighting in the dish machine room, uncovered floor baseboards, and an unsecured ceiling tile with exposed insulation. These issues were confirmed by interviews with the Food Service Director and Administrator and were not in compliance with facility policies and professional standards.
The facility did not maintain complete and accurate medical records for three residents, including instances where a Nurse Practitioner note referred to the wrong individual and where diagnoses such as Osteoporosis and Depression were omitted from official records and face sheets, despite being referenced in care plans and medication orders.
Live roaches were observed in a resident's bathroom and the conference room, with a resident reporting repeated sightings and direct contact with pests. A housekeeper confirmed frequent sightings of roaches and droppings in various facility areas. The administrator acknowledged ongoing reports of pests and stated that regular pest control treatments were in place, as required by facility policy.
A resident with severe cognitive impairment and a history of falls was found in bed without access to her call light, which was on the floor under the bed. The resident, who required assistance from two staff members and was at risk for falls, reported having to yell for help. Staff interviews confirmed the call light was not within reach, contrary to the care plan and facility policy.
A resident with end stage renal disease and intact cognition had an Out of Hospital Do Not Resuscitate (OOH-DNR) form that was rendered invalid because the physician failed to provide a required signature on the lower portion of the form. The Social Worker, responsible for ensuring proper execution of these forms, confirmed the oversight and acknowledged the form's invalidity. Facility policy and state guidance require all necessary signatures for such forms to be valid.
A medication aide left a computer unlocked and unattended with a resident's medication list visible, failing to protect the resident's confidential health information. The aide was unaware of the requirement to lock the computer screen, and the Director of Nursing confirmed that staff are expected to secure electronic records in compliance with HIPAA.
Three residents with complex medical conditions had their required MDS assessments initiated but not completed or submitted as mandated. The MDS coordinator confirmed the oversight, and the DON stated that timely completion and submission of MDS assessments is expected according to facility policy.
Three residents with complex medical conditions had their MDS assessments completed but not transmitted to CMS within the required timeframe, as confirmed by staff interviews. The delay was attributed to an oversight and a shortage of MDS nursing staff, leaving assessments in 'export ready' status instead of being submitted as required by facility policy.
A resident with a documented diagnosis of depression and prescribed medications for this condition did not have depression included on their quarterly MDS assessment. The omission was confirmed by the MDS nurse and DON as an oversight, despite facility policy requiring comprehensive inclusion of all diagnoses.
Two residents were admitted without their baseline care plans reflecting essential physician orders: one resident's use of anti-coagulant and anti-platelet medications was omitted, and another resident's Kosher diet preference was not included until several days after admission. Staff interviews revealed uncertainty about including these elements in the baseline care plans, despite facility policy requiring such information within 48 hours.
A resident with depression was administered both buspirone and escitalopram for the same condition without documented justification for duplicative therapy. The DON was unaware of the concurrent use, and pharmacy reviews did not address the issue, despite facility policy prohibiting excessive dosages of psychotropic medications.
Surveyors found expired medications stored in a medication room, a refrigerated medication kept at room temperature in a nurse's cart, and a nasal spray labeled only with a resident's initials and last name. Staff interviews revealed confusion about responsibility for removing expired drugs and ensuring proper storage and labeling, resulting in multiple violations of medication management protocols.
A resident with a documented need for a no pork Kosher diet did not receive appropriate meals for five days after admission, despite clear orders and care plan documentation. The resident continued to receive pork products, and staff lacked knowledge about Kosher dietary requirements. The facility did not have a policy for specialized diets, and the dietician was not consulted to ensure the resident's religious and cultural dietary needs were met.
A nurse failed to sanitize her hands between glove changes while providing wound care to a resident with multiple complex wounds. The nurse changed gloves after touching both clean and dirty surfaces but did not perform hand hygiene as required by facility policy, which was confirmed by the DON and acknowledged by the nurse during interviews.
A resident using a facility-provided loaner wheelchair for rehabilitation reported that the right brake was broken and did not fully engage, resulting in incomplete braking during transfers. Therapy staff attempted to fix the issue but were unable to do so and reported it to the DOR, who confirmed the problem. The facility did not have a specific wheelchair maintenance policy, relying instead on a general equipment maintenance policy.
A resident with severe cognitive impairment and multiple medical conditions did not receive a physician-ordered fortified meal plan due to a failure in updating the meal ticket system, resulting in staff not being alerted to provide the required extra calories, fats, and carbohydrates as part of the therapeutic diet.
A resident with multiple pressure ulcers did not have their wound care documented on several occasions, despite receiving the care. Nurses admitted to forgetting to document due to being busy or because the resident preferred care from a specific nurse. The facility's policy requires all skilled services to be documented, which was not followed, potentially leading to improper wound care.
Two residents in an LTC facility did not receive necessary wound care as ordered, leading to a deficiency in pressure ulcer management. One resident missed care on two occasions due to a busy charge nurse and lack of communication, while another was not treated because the wound care nurse could not locate them. Despite no immediate negative effects, the deficiency posed a risk of potential wound infections.
A resident with complex medical conditions did not have a comprehensive person-centered care plan addressing their ADL needs, catheter use, diagnoses, dietary needs, therapy, and discharge planning. The facility's staff interviews revealed a lack of clarity and responsibility in the care planning process, leading to unmet resident needs.
A facility failed to administer Carvedilol to a resident as per physician's orders, leading to a deficiency in providing routine and emergency drugs. The resident, with conditions including hypertension, did not receive the medication due to a lack of parameters in the order and miscommunication among staff. The DON assumed the medication was held for best practice, but the physician expected nurses to apply parameters, which was not done.
A facility failed to maintain accurate medical records for a resident, documenting an incorrect heart rate of 2 bpm. The resident had a history of acute kidney failure, heart disease, and hypertension, requiring careful monitoring. The error was not identified by the DON or ADONs, responsible for record accuracy, despite facility policies mandating precise documentation.
A resident admitted to the facility did not receive prescribed medications for several days due to a failure to transcribe and implement hospital discharge orders. The resident, with multiple medical conditions, was affected by communication breakdowns and procedural errors among facility staff, leading to a delay in medication administration.
The facility failed to maintain a safe, clean, and homelike environment for residents, with issues including unrepaired wall scrapes, burnt-out light bulbs, and water damage. The Maintenance Director was unaware of work orders for these repairs, and the Administrator acknowledged the problems but noted that staff could report maintenance issues electronically.
The facility failed to serve food at safe and appetizing temperatures, as reported by two residents who received cold meals on multiple occasions. Staff acknowledged the issue and sometimes reheated or replaced the meals, but temperature checks confirmed that food was often below recommended levels.
The facility failed to meet food service safety standards, including improper use of facial hair restraints, wearing jewelry during food preparation, unlabeled and expired food items, improperly stored cereal, and a dirty can opener. These lapses were acknowledged by the Dietary Manager.
A facility failed to ensure medications were not left on a resident's bedside table. The resident, who had intact cognition, had over-the-counter medications on his bedside table without a physician's order to self-administer. Staff confirmed the medications had been there for an extended period, and no self-medication assessment had been conducted.
A facility failed to maintain infection control when an RN administered eye drops to a resident without changing gloves or sanitizing hands after touching contaminated objects in the resident's environment. The resident had multiple diagnoses and required extensive assistance. The RN had received infection control training and passed competency checks, and the DON confirmed the need for proper glove changes and hand hygiene.
The facility failed to update a resident's care plan to reflect that he was performing his own colostomy care, despite having a BIMS score indicating intact cognition and a physician's order for colostomy bag changes. Staff interviews revealed that key personnel were unaware of the resident's self-care activities, leading to a lack of comprehensive care planning.
The facility failed to properly dispose of garbage and refuse, leaving the garbage disposal unit's lid open and exposing stacked bags of garbage. Both the Food Service Director and the Administrator confirmed that the lid should have remained closed to prevent pests. The facility's policy indicated that food waste should be disposed of in covered waste cans.
Failure to Disinfect Shared Blood Pressure Cuff Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain its infection prevention and control program by not cleaning shared patient-care equipment, specifically a blood pressure cuff, between use on two residents. On the observed date, Medication Aide (MA) A took the blood pressure of Resident #1, returned the cuff to the medication cart, and did not sanitize it. Later the same shift, MA A used the same unsanitized cuff to take the blood pressure of Resident #2 and again placed it back on the cart without cleaning. These actions occurred despite the facility’s written policy stating that when common-use equipment for multiple residents is unavoidable, it must be cleaned and disinfected before use on another resident. Resident #1 was a male resident with diagnoses including pneumonitis, type 2 diabetes mellitus, and hypertension. His most recent quarterly MDS showed a BIMS score of 09, indicating moderate cognitive impairment, and documented an active diagnosis of hypertension with no infections in the seven days prior to the assessment and no antibiotic use in the same period or since admission/entry. Resident #2 was a female resident with diagnoses including cerebral infarction, COPD, and hypertension. Her admission MDS documented a BIMS score of 00, indicating severe cognitive impairment, an active diagnosis of hypertension, and no infections or antibiotic use in the seven days prior to the assessment or since admission/entry. During interview, MA A acknowledged not sanitizing the blood pressure cuff between residents, explaining she was trying to locate residents and administer medications on time. She stated she previously used sanitizing wipes but they were not on her cart that day, and that in their absence she would sometimes use hand sanitizer on paper towels to clean the cuff. She also stated it was important to sanitize the cuff between residents because bacteria on the cuff could be carried from one resident to another. The DON stated that infection control staff and nurse managers were expected to perform skill checks, observations, and in-services for staff administering medications, that ADONs were responsible for daily monitoring of medication administration procedures, and that nurses and medication aides were responsible for restocking sanitizer wipes on the carts each shift. The DON and the Administrator both stated their expectation that staff use sanitizing wipes to clean blood pressure cuffs between residents and that failure to do so placed residents at risk for infections.
Failure to Provide Hot Water for Resident Showers and Maintain Comfortable Bathing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with hot water in their own showers, resulting in an inability to ensure a warm and comfortable bathing experience for multiple residents over an extended period. For one cognitively impaired female resident with a history of stroke, vascular dementia, and total dependence on staff for personal care, record review showed she was scheduled for bathing three times weekly, but there were no showers, baths, or sponge baths documented in her medical record for nearly a month. Her care plan listed showers/baths as not applicable, and a grievance from her family reported no hot water to provide a shower or bath, with no documentation of how this concern was resolved. When water temperatures were tested in her room, the shower measured 94°F and the sink 77°F after running for three minutes. A cognitively intact male resident with paraplegia, type 2 diabetes, and a need for maximal assistance with showering/bathing reported that there had been no hot water in his room for 2–3 weeks. His care plan did not identify his showering/bathing needs. ADL documentation showed a mix of refusals, full body baths, and one shower during the review period. He stated that if staff could not find hot water, he refused showers, and although staff suggested he shower in another resident’s room, he declined because he wanted to shower and change in his own room. He reported accepting sponge baths multiple times when staff could find hot water, but expressed a preference for showers with clean hot water in his own room. Temperature checks in his room showed both the shower and sink at 80°F after running for three minutes. Another cognitively intact male resident with cirrhosis, type 2 diabetes, and a need for assistance with personal care was documented as requiring two staff for bathing/showering and having set-up assistance for showering. ADL records showed frequent showers earlier in the month and a full body bath later, but he reported he was only taking showers once a week because the water was too cold. He stated staff were aware of the cold water, and when he refused showers due to the temperature, staff simply accepted the refusal; he sometimes accepted bed baths because they were warmer, and at other times took cold showers when he could not tolerate going without. Temperature checks in his room showed shower water at 80°F and sink water at 77°F after three minutes. Staff interviews confirmed ongoing hot water problems affecting multiple rooms on one wing, including those of the three residents. The Maintenance Director reported fluctuating water temperatures since the end of December, acknowledged that most rooms on one wing were affected, and stated that all facility management, including the Administrator, were aware of the lack of hot water. CNAs described that some rooms had hot water and some did not, and that they were taking residents without hot water to other residents’ rooms of the same gender or to empty rooms with hot water, if available. They also reported using hot water from the dining room sink or coffee machine for bed or basin baths, and one CNA described filling containers with hot water from another room and pouring them over residents in their own showers to simulate a shower. Staff stated that some residents refused to bathe in other residents’ rooms or refused bed baths when hot water was not available. The DON, who was new to the facility, acknowledged that residents should be showered every other day, that hot water availability varied by room and day, that Resident #1’s family had complained about hot water and showers, and that moving shower locations could be confusing for residents with dementia. The facility’s bath/shower policy required adjusting water to a comfortable temperature before turning the stream toward the resident, which was not consistently achievable due to the lack of hot water in affected rooms.
Failure to Maintain Safe and Consistent Hot Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain resident room hot water temperatures within the required range of 100–110°F on both the 2nd and 3rd floors, resulting in water that was either too hot or too cold in multiple occupied rooms. During an observation of water temperature measurements conducted by the Maintenance Director, several resident room showers and sinks registered 118°F, while others measured as low as 77–94°F. A facility maintenance water temperature log from January documented multiple resident rooms with hot water temperatures around 80–94°F, further confirming ongoing problems with maintaining appropriate temperatures in resident areas. Nursing staff interviews showed that the issue had been present for some time and that there was no consistent, formal process for reporting or addressing it. An LVN reported there had been no complaints of water being too hot but acknowledged that CNAs were instructed to use basins to mix water if it was too hot or too cold and to seek alternative rooms for showers when necessary. The LVN was unsure whether staff consistently reported water temperature problems through the computer system as required and stated that most of the time they simply informed the Maintenance Director in person. The LVN also stated that the Maintenance Director’s typical response was to advise staff to let the water run for a few minutes or to find an alternative location. Interviews with facility leadership and maintenance staff confirmed that fluctuating water temperatures had been an ongoing issue since approximately the end of December 2025 or January 2026. The Maintenance Director admitted he was uncertain of the regulatory temperature range he was required to maintain and could not clearly describe what specific plumbing issues had been repaired or provide contact information for the plumbers. The Administrator acknowledged awareness of resident complaints about lack of hot water and confirmed that grievances had been received, including one from a resident’s family member. The Administrator and DON both indicated there was no facility policy for water temperatures or the physical environment. The Regional Maintenance Director and Maintenance Director both agreed that not maintaining water temperatures in resident rooms could cause scalding or other physical injuries, and they confirmed that responsibility for maintaining water temperatures rested with the facility’s maintenance department.
Failure to Develop Comprehensive ADL Care Plans for Two Residents
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents. For one resident, a female with sequelae of cerebral infarction, vascular dementia without behavioral disturbance, and a documented need for assistance with personal care, the quarterly MDS showed she required maximal assistance with bathing and was totally dependent on staff for personal hygiene and toileting. Despite these assessed needs, her ADL self-care performance deficit care plan, initiated in 2023 and last revised in late 2025, listed shower/baths as "N/A" (not applicable), and therefore did not reflect her actual bathing and showering requirements as identified in the MDS and clinical record. For another resident, a male with paraplegia, type 2 diabetes mellitus, and a need for assistance with personal care, the 5-day Medicare MDS documented that he was cognitively intact with a BIMS score of 15 and required maximal assistance with showering/bathing and transfers, total dependence for toileting, dressing, and wheelchair use, moderate assistance for certain bed mobility tasks, and supervision for rolling. His ADL self-care performance deficit care plan, however, did not identify these specific ADL needs and only stated that he should be encouraged to participate to the fullest extent possible with each interaction. Interviews with the new, inexperienced MDS Coordinator and the DON confirmed that the MDS Coordinator was responsible for care plans, was focused mainly on skilled residents, was still in training for LTC care plans, and that the care plans for both residents were missing required information and did not match the MDS assessments or actual care needs, contrary to the facility’s written policy on comprehensive person-centered care planning.
Incomplete Documentation of ADL Bathing Care in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident in accordance with accepted professional standards and its own policy. A female resident with sequelae of cerebral infarction, vascular dementia without behavioral disturbance, and a need for assistance with personal care had a quarterly MDS showing a BIMS score of 00, indicating her cognition could not be scored and she could not be understood, and that she required maximal assistance with bathing and was totally dependent on staff for personal hygiene and toileting. Her ADL self-care performance deficit care plan listed shower/baths as not applicable. Review of her ADL completed bath activity for the last 30 days showed she was on a Monday, Wednesday, and Friday bathing schedule, but there were no showers, baths, or sponge baths documented in the medical record for the period reviewed. Further record review of the resident’s shower sheets for the same time frame showed multiple showers and a bed bath were actually provided on specific dates, demonstrating that care was given but not reflected in the Nursing Assistant ADL Flow Sheet or the medical record. During interviews, the DON stated she did not know if shower sheets were part of the resident’s medical record and indicated that Medical Records was responsible for documentation uploads, emphasizing the importance of a complete and accurate medical record to account for all care provided. Medical Records staff stated that shower sheets were not uploaded into the medical record and were considered for facility information only, although they were collected and stored for five years. The facility’s policy on the content of the medical record, however, listed Nursing Assistants ADL Flow Sheets as part of the required contents, underscoring that the resident’s ADL bathing care was not accurately documented in the official clinical record.
Failure to Maintain Safe and Consistent Hot Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment by not maintaining appropriate hot water temperatures in multiple resident rooms. Surveyors measured water temperatures in five residents’ sinks and found that four rooms had water temperatures below 100°F, specifically ranging from 78.1°F to 80°F, and one room had water at 118°F, above the 110°F upper limit cited in the report. These findings involved residents with varying levels of cognitive function, including residents with severe cognitive impairment, moderate cognitive impairment, dementia, weakness, and a recent admission for sepsis. During observations, the Maintenance Director used a dial instant-read thermometer at each resident’s sink and confirmed the out-of-range temperatures. One cognitively intact resident reported being told to use wipes or hand sanitizer when the water was not hot enough to ensure hand hygiene. Another resident’s responsible party reported that the water was too cold for bed baths, requiring nursing staff to obtain hot water from another location before the resident could receive a bath. A newly admitted resident’s family member stated they had not yet noticed the water temperature. One resident with hot water at 118°F reported that hot water was available and had not affected daily life. Interviews with facility staff revealed that the water temperature problems began after work was done at a connecting facility that shared utilities, during which water had been shut off and, afterward, some rooms did not have hot water. The Maintenance Director stated that since that time, some rooms lacked hot water and residents were being moved or supplied hot water from elsewhere. The Interim Administrator and Operations Manager reported that the water temperature had been problematic for 2 to 3 weeks, and the DON stated that hot water had been out intermittently since a prior month, working on and off. The DON also stated that residents were made aware when their hot water was not working and were educated to use hand sanitizer or offered wipes for hand cleaning. When a policy specific to water temperatures was requested, the Operations Manager reported that the facility did not have a water-specific policy, though the existing Environmental Safety policy stated the facility provides a safe, functional, sanitary, and comfortable environment for residents.
Repeated Late Administration of Scheduled Medications for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely and accurate medication administration for two residents. For Resident #1, who had hypertension, low back pain, and atrial fibrillation and was severely cognitively impaired (BIMS score 5/15), multiple scheduled morning medications ordered for 7:00 AM were repeatedly administered between approximately 10:00 AM and 10:45 AM over three consecutive days. These medications included apixaban, polyethylene glycol, thiamine, a multivitamin-mineral supplement, megestrol acetate, levetiracetam, ascorbic acid, metoprolol tartrate, and a lidocaine patch. Medication Administration Audit Reports dated 01/08/26 documented that on 01/06/26, 01/07/26, and 01/08/26, the same staff member (MA A) administered these medications significantly later than the scheduled time. Resident #2, who had depression, acute on chronic right heart failure, hypertension, a non-ST elevation myocardial infarction, and severe cognitive impairment (BIMS score 1/15), also experienced late administration of multiple 7:00 AM medications. The order summary for this resident included Lexapro, artificial tears, aspirin, calcium, Namenda, Aldactone, ferrous sulfate, carvedilol, and Bumex. The Medication Administration Audit Report for 01/08/26 showed that all of these medications, scheduled for 7:00 AM, were administered at 10:57 AM by the same medication aide, MA A. These findings demonstrated that the facility did not ensure medications were administered according to the ordered times. In interviews, MA A acknowledged that medications for these residents were given late and stated she was trying to coordinate medication administration around therapy sessions and resident appointments, but admitted this was not an excuse. The DON stated that it was not a pattern for residents to receive medications late and that if medications were late, the physician would be called, and noted that therapy and family visits could affect administration times. The Interim Administrator reported that the facility did not have a policy specifying the time frame for when medications should be given, and that staff followed an internal “Medication Times” reference sheet indicating day-shift medication times between 7:00 AM and 10:00 AM and between 12:00 PM and 2:00 PM. The survey findings concluded that the facility failed to provide pharmaceutical services that assured accurate acquiring, receiving, dispensing, and administering of medications, which could place residents at risk of not receiving the intended therapeutic benefit and worsening of chronic conditions.
Failure to Ensure Privacy for Resident with Foley Catheter
Penalty
Summary
A male resident with severe cognitive impairment, legal blindness, and an indwelling urinary catheter was observed walking in the hallway with his Foley catheter bag attached to his right calf, visibly over half full of urine and lacking a privacy cover. The resident was assisted by a CNA, who stated she had not seen a privacy cover for the bag and was unsure who was responsible for ensuring privacy covers were in place. The resident himself was unaware of whether a privacy cover was present due to his blindness and expressed indifference about its use. Record review showed that the resident's care plan and physician orders required the use of a privacy bag for the catheter, and the facility's policy also mandated covering the drainage bag to maintain dignity. Interviews with facility staff, including the CNA, LVN, Operations Manager, and DON, revealed inconsistent understanding and implementation of responsibility for ensuring privacy covers were used. The LVN assigned to the resident acknowledged seeing the resident without a privacy cover and admitted not placing one during his shift, despite having access to privacy bags and having received training on their use. The Operations Manager and DON both affirmed the importance of privacy covers and stated that staff had received training and that supplies were available. However, the observation and staff interviews demonstrated a failure to ensure the resident's personal privacy as required by facility policy and the resident's care plan.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as required by professional standards. Specifically, the treatment administration records (TARs) for all three residents did not consistently document the completion of wound care treatments on multiple dates, despite physician orders and care plans indicating that daily wound care was necessary. The missing documentation was identified through observations, interviews, and record reviews during a complaint investigation. One resident, a male with a history of type 2 diabetes, foot ulcer, cirrhosis, peripheral vascular disease, and stage 4 pressure ulcers, was observed with bandaged wounds and reported receiving treatment for two wounds. His TARs for September and October did not reflect completion of wound care on several dates, even though daily treatment was ordered. Another resident, a female with severe cognitive impairment, unstageable pressure ulcer, morbid obesity, diabetes, and chronic respiratory failure, also had missing documentation for required daily wound care on specific dates. A third resident, a male with diabetes, MRSA infection, anemia, end-stage renal disease, and a below-knee amputation, had similar gaps in documentation for daily wound care to his left heel, right buttocks, and amputation site. Interviews with the wound care nurse, ADON, and DON confirmed that the TARs were not marked as completed on the identified dates. Staff indicated that the absence of documentation could be due to treatments being marked elsewhere, electronic medical record glitches, or the treatments not being performed or recorded. The only way to verify if the treatments were provided was to ask the nurse on duty, as no refusals or reasons for missed treatments were documented. The lack of documentation meant there was no reliable record of whether the prescribed wound care was actually administered.
Unsecured Medication Cart Found Unattended on Hall A
Penalty
Summary
A deficiency was identified when the medication cart on the 3rd floor Hall A was found to be unattended and not properly secured. Observation revealed that although the locking mechanism on the cart was engaged, each drawer could be opened when pulled, allowing access to both prescribed and over-the-counter medications. The LVN responsible for the cart was seated at the nurse's station and, upon inspection, confirmed that the drawers were not secured. The LVN acknowledged responsibility for ensuring the cart was locked and suggested that a slightly ajar drawer may have prevented the lock from engaging properly. Interviews with the LVN, ADON, and DON confirmed that only authorized personnel should have access to medications and that the cart should be locked or attended at all times. The facility's policy requires all drugs and biologicals to be stored in locked compartments accessible only to licensed or authorized staff. The failure to secure the medication cart meant that medications were accessible to unauthorized individuals, contrary to facility policy and accepted professional standards.
Failure to Complete Timely Resident Assessments
Penalty
Summary
A deficiency was identified when the facility failed to assess a resident completely and in a timely manner upon admission and at required intervals, specifically at least every 12 months. The report notes that the necessary comprehensive assessment was not conducted as mandated, resulting in noncompliance with assessment requirements.
Failure to Develop and Implement 48-Hour Immediate Needs Plan for New Admission
Penalty
Summary
A plan to address a resident's most immediate needs within 48 hours of admission was not created or implemented. The deficiency occurred due to the facility's failure to ensure that a process was in place to assess and meet the immediate needs of newly admitted residents within the required timeframe. There is no mention of specific residents, their medical history, or their condition at the time of the deficiency in the report.
Failure to Provide Proper Indwelling Catheter Care and Securement
Penalty
Summary
A deficiency occurred when a resident with an indwelling urinary catheter did not receive appropriate catheter care as required by facility policy and physician orders. During an observation, a CNA provided incontinent and catheter care but failed to clean the catheter tubing itself, only cleaning the perineum, thigh folds, shaft and head of the penis, and around the catheter insertion site. The CNA later acknowledged she was supposed to clean the catheter by holding it and wiping from the tip away from the body, but did not do so due to distractions and feeling nervous during the care. Additionally, the resident's catheter was not secured with a leg strap as ordered by the physician and facility policy, and the CNA confirmed the resident did not have a leg strap on before or after a shower. Record review showed active orders for securing the catheter with a leg strap or anchor to minimize injury and accidental removal, and for changing the leg strap weekly and as needed. The facility's policy also required cleaning the catheter in a downward motion from the urinary meatus at least four inches down. Interviews with the DON and CNA confirmed expectations for catheter care and monitoring, and the CNA admitted to not following proper procedure during the observed care. The resident, who was cognitively intact and had a history of catheter displacement, UTI, and diabetes, did not express concerns about his care.
Failure to Document Weekly Skin Assessments in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, weekly skin assessments for a male resident with diagnoses including type 2 diabetes mellitus, muscle weakness, and dysphagia were not documented for two separate weeks. The resident was identified as being at risk for pressure ulcers, and his care plan required weekly monitoring and documentation of skin integrity. Review of the electronic medical record and progress notes confirmed the absence of required weekly skin assessments for the specified weeks, and no alternative documentation was found to explain the omission. Interviews with the treatment nurse and the DON revealed that both floor nurses and the treatment nurse shared responsibility for completing and documenting weekly skin assessments. The DON confirmed that if an assessment was not documented, it was considered not to have occurred, and she was unable to locate the missing assessments. The facility's policy required weekly head-to-toe skin checks by a licensed nurse, with findings documented accordingly, but this was not followed for the resident in question during the identified weeks.
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, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Safe and Homelike Resident Environment Due to Broken and Unsafe Bathroom Equipment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents, as evidenced by broken and unsafe bathroom equipment. Two residents were affected by a broken shower faucet handle in their shared bathroom, which had been missing for at least two weeks to over a month. Both residents had to use a shower in another resident's room, and multiple work orders for the repair were placed in the facility's TELS system, but the issue remained unresolved. Staff interviews revealed a lack of awareness about the residents' use of alternative showers and confirmed the maintenance director position was vacant at the time. Another resident was provided with a toileting chair that had a rusty metal support frame and peeling paint, which caused discomfort and concern for the resident. The resident reported that the peeling paint would scrape her skin and could get into her private areas, and that the chair was too small for her needs. Despite complaints to staff, the original chair remained in her bathroom even after she was given a larger, more suitable chair. Staff interviews indicated that no work order had been submitted for the repair or replacement of the unsafe chair, and the condition of the equipment was not known to the nurse interviewed. Record reviews confirmed that the facility's policy required all equipment to be maintained in good working order to ensure resident safety and wellbeing. However, the lack of timely repairs and the continued presence of unsafe equipment in resident bathrooms demonstrated a failure to uphold this policy. The absence of a maintenance director contributed to delays in addressing these issues, as work orders were not completed and staff were unclear about who was responsible for maintenance tasks.
Failure to Identify Mental Illness on PASRR Level I Screenings
Penalty
Summary
The facility failed to accurately identify and document mental illness diagnoses on the Preadmission Screening and Resident Review (PASRR) Level I assessments for three residents. Specifically, two residents with major depressive disorder and one resident with schizoaffective disorder and bipolar disorder were not recognized as having a mental illness on their PASRR Level I screenings, despite clear documentation of these diagnoses in their medical records, medication orders, and care plans. The PASRR Level I forms for all three residents indicated 'No' in response to the question regarding evidence of mental illness, which was inconsistent with other clinical documentation. Record reviews showed that each resident had a documented diagnosis of a qualifying mental illness and was receiving psychotropic medications for these conditions. The Minimum Data Set (MDS) assessments and care plans for these residents also reflected their psychiatric diagnoses and related interventions. However, the PASRR Level I screenings did not reflect this information, resulting in a lack of appropriate identification for further evaluation or services as required by PASRR regulations. Interviews with facility staff revealed a lack of understanding regarding the correct completion of PASRR Level I screenings, particularly in cases where residents had documented mental illness diagnoses. The MDS nurse and DON both indicated that hospital PASRR assessments were often submitted without updates to reflect current diagnoses, and that negative PASRR Level I results were routinely accepted even when residents were on psychotropic medications for mental illness. The facility's policy required coordination with local authorities for further evaluation when a PASRR Level I indicated possible mental illness, but this process was not followed due to the inaccurate screenings.
Failure to Develop and Update Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for several residents, as required by policy. For one resident with severe cognitive impairment, the care plan did not address her diagnoses of allergies and constipation, despite these being documented in her medical record. Another resident, who had a history of encephalopathy and pancreatic cyst, had his care plan listing an indwelling catheter even after it had been removed, and this was confirmed by both observation and staff interview. A third resident, with moderate cognitive impairment and a high risk for wandering, had a physician's order for a WanderGuard device following increased wandering behavior. However, the use of the WanderGuard was not reflected in the care plan, and the resident was observed wearing the device without understanding its purpose. Staff interviews confirmed that the care plan should have been updated to include this intervention but was overlooked due to staffing limitations. A fourth resident, admitted and readmitted with a nephrostomy tube, did not have the presence or care of the nephrostomy tube included in her care plan, despite orders to monitor its output. Observation confirmed the presence of the nephrostomy tube, and staff acknowledged that it was not included in the care plan. Facility policy requires that all identified medical and nursing needs be addressed in the care plan, but this was not done for these residents.
Multiple Food Service Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations, including the absence of a garbage bin under the hand sink, which resulted in staff carrying dirty hand towels across the kitchen to dispose of them. Additionally, two 5 lb containers of cottage cheese and a container of dried rice in storage were found undated, contrary to facility policy requiring all opened and refrigerated food items to be labeled with the date opened and a use-by date. The dish machine room was noted to have two non-functioning overhead fluorescent light bulbs, and two sections of floor baseboard in the main kitchen area were uncovered, exposing open surfaces that could collect dust. A ceiling tile in the main kitchen was also unsecured, revealing exposed insulation underneath. Interviews with the Food Service Director and Administrator confirmed that these conditions did not meet the facility's own policies for sanitation, infection control, and food storage. The lack of proper dating on food items, inadequate lighting, exposed baseboards, and unsecured ceiling tiles with visible insulation were all acknowledged as failures to maintain professional standards for food service safety. These deficiencies were identified through direct observation and staff interviews, and were supported by a review of facility policies and the FDA Food Code.
Incomplete and Inaccurate Medical Records Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents. For one resident, Nurse Practitioner notes in the clinical record referred to another resident, indicating a mix-up or misfiling of documentation. Another resident's diagnosis of Osteoporosis, which was referenced in the care plan and medication orders, was not included in the resident's official diagnoses list or face sheet. Similarly, a third resident's diagnosis of Depression, which was documented in the care plan and progress notes and for which medication was ordered, was not reflected in the diagnoses list or face sheet. These deficiencies were confirmed during an interview with the Director of Nursing, who acknowledged that all diagnoses should be accurately listed on the resident face sheet, as this information is shared with outside medical providers and hospitals. The facility's policy requires that each resident have a separate medical record with prompt and appropriate entries by all healthcare professionals involved in the resident's care.
Failure to Maintain Pest-Free Environment
Penalty
Summary
Surveyors observed live roaches in multiple areas of the facility, including a resident's bathroom and the first-floor conference room. In the resident's bathroom, a live roach was seen crawling on the wall near a vent, and another was observed on the surveyor's bag in the conference room. The affected resident reported seeing roaches coming out of the vents in his shower room and recounted an incident where a roach crawled on him in bed two nights prior. He also stated that although the pest control company had sprayed his room, he did not feel the treatment was effective. A housekeeper interviewed during the survey confirmed seeing roaches under beds, in the breakroom, laundry room, and noted droppings in some bathrooms, typically upon first entering rooms and turning on the lights. The facility administrator acknowledged receiving reports of roaches, particularly from residents on the second floor, and stated that the facility had a contract with a pest control company that provided regular treatments. Review of the facility's pest control policy indicated a requirement to maintain an effective pest control program to keep the facility free of pests and rodents.
Failure to Ensure Call Light Accessibility for Resident with Cognitive Impairment
Penalty
Summary
A deficiency was identified when a resident with major depressive disorder, dementia, and diabetes mellitus was found in bed without access to her call light, which was observed on the floor under the bed. The resident, who had severe cognitive impairment and was assessed as unsteady on her feet and requiring assistance from two staff members, stated that she had to yell for help and did not know how the call light ended up on the floor. The resident's care plan, which was revised to address her risk for falls due to muscle weakness, included an intervention to ensure the call light was within reach. Interviews with facility staff confirmed that the assigned nurse was unaware of how the call light became inaccessible but acknowledged the potential for negative outcomes if the resident could not call for assistance. The DON emphasized the importance of call light accessibility and stated that charge nurses monitor this during daily rounds. Facility policy requires that the call light be placed within the resident's reach before staff leave the room.
Invalid OOH-DNR Form Due to Missing Physician Signature
Penalty
Summary
A deficiency occurred when a resident's Out of Hospital Do Not Resuscitate (OOH-DNR) form was found to be invalid due to a missing physician signature. The resident, who had diagnoses including end stage renal disease and dependence on renal dialysis, was cognitively intact and had elected DNR status as documented in the care plan. The resident had signed the OOH-DNR form, and the physician had signed the upper portion, but failed to sign the required lower portion of the form. During interviews, the Social Worker confirmed that two signatures were required from all parties on the OOH-DNR form and acknowledged that the missing physician signature rendered the form invalid. The Social Worker stated it was her responsibility to ensure the forms were correctly executed and identified the error as an oversight. The DON also confirmed the expectation that all advance directives, including OOH-DNR forms, be properly completed to honor residents' end of life wishes. Facility policy and state guidance both require correct completion of these forms.
Failure to Secure Electronic Medical Records Exposes Resident Information
Penalty
Summary
A medication aide (MA) failed to maintain the privacy and confidentiality of a resident's personal and medical records by leaving a computer unlocked and unattended for seven minutes, with the screen displaying the resident's morning medication list. The incident was observed during medication administration, and the computer was left facing the hallway, making the information potentially visible to unauthorized individuals. The MA later stated she was unaware of the requirement to lock the computer screen and believed that minimizing the screen was sufficient to protect the information. The resident involved had a history of chronic obstructive pulmonary disease, heart failure, and atrial fibrillation, and was assessed as having moderate cognitive impairment. The Director of Nursing (DON) was not aware of the incident until informed and stated that the expectation was for all nursing staff to lock computer screens when unattended, in accordance with HIPAA regulations. Facility policy required that protected health information be kept safe, confidential, and protected.
Failure to Complete and Submit Timely MDS Assessments
Penalty
Summary
The facility failed to complete and submit required Minimum Data Set (MDS) assessments for three residents within the mandated timeframes. For one resident with Type 2 Diabetes Mellitus and muscle weakness, both a quarterly and an annual MDS assessment had been initiated but not completed. Another resident with hemiplegia and speech deficits following a cerebral infarction had two quarterly MDS assessments initiated but left incomplete. A third resident, diagnosed with a femur fracture and Type 2 Diabetes Mellitus, also had a quarterly MDS assessment that was started but not finished. These incomplete assessments were identified through record reviews, which showed that the MDS assessments had been initiated but not finalized for each resident. During interviews, the MDS coordinator confirmed that the assessments had not been completed due to oversight and acknowledged responsibility for ensuring timely completion and submission to CMS. The Director of Nursing stated that her expectation was for MDS assessments to be initiated, completed, and exported to CMS promptly. Facility policy requires that accurate and complete MDS data be electronically transmitted to the CMS system, but this process was not followed for the residents in question.
Failure to Timely Transmit MDS Assessments Due to Staffing Shortages
Penalty
Summary
The facility failed to encode and transmit Minimum Data Set (MDS) assessments to the State and CMS within the required timeframe for three residents. For one resident with hemiplegia and lupus anticoagulant syndrome, the quarterly MDS assessment was completed but not transmitted, remaining in 'export ready' status. Another resident with type 2 diabetes mellitus, diabetic neuropathy, and sequelae of cerebral infarction also had a completed quarterly MDS assessment that was not transmitted. A third resident, admitted with a femur fracture, aftercare following joint replacement, and hypertension, had an entry MDS assessment completed but not transmitted within 14 days of completion, as required. Interviews with facility staff confirmed that the MDS assessments were completed but not transmitted due to an oversight and staffing shortages, specifically a vacant MDS nurse position. The DON acknowledged that the responsibility for transmitting MDS assessments lay with the MDS nurse and that the delay was related to having only one MDS nurse on staff at the time. Facility policy requires timely electronic transmission of accurate and complete MDS data to the CMS system.
Failure to Accurately Reflect Depression Diagnosis in Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their current diagnoses. Specifically, a resident with a documented diagnosis of depression, as indicated on the face sheet and supported by ongoing physician orders for Buspirone and Escitalopram, did not have this diagnosis included on their quarterly Minimum Data Set (MDS) assessment. The resident's medication administration records confirmed that both medications for depression were being administered as ordered during the review period. Interviews with the MDS nurse and the Director of Nursing (DON) confirmed that the omission of the depression diagnosis from the MDS was an oversight. The facility's policy requires that comprehensive assessments include all disease diagnoses and history, but this was not followed in this instance, resulting in an inaccurate assessment for the resident.
Failure to Include Critical Medications and Dietary Preferences in Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans that included all necessary instructions to provide effective and person-centered care for two residents within 48 hours of admission. For one resident with heart failure and atrial fibrillation, the baseline care plan did not include the use of prescribed anti-coagulant and anti-platelet medications, despite physician orders for Apixaban and Clopidogrel Bisulfate. The MDS nurse indicated that these medications were not automatically triggered by the baseline care plan assessment and was unsure if they should be included, even though they have significant side effects that require monitoring. For another resident admitted with a femur fracture and irritable bowel syndrome, the baseline care plan did not initially include the resident's preference for a Kosher diet, despite a physician order specifying this dietary requirement. The intervention for a Kosher diet was not added to the care plan until five days after admission. Interviews with facility staff confirmed that baseline care plans are initiated by the DON and completed by the admitting nurse, and are due within 48 hours of admission, but did not consistently address all physician and dietary orders as required by facility policy.
Failure to Prevent Duplicative Psychotropic Medication Therapy
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Chronic Obstructive Pulmonary Disease, heart failure, and depression was found to be receiving two medications, buspirone and escitalopram, both prescribed for depression. The resident's physician orders indicated that both medications had been administered concurrently since December of the previous year, with no documentation justifying the need for duplicative therapy. The resident's care plan included interventions to administer medications as ordered, but did not address the duplication. Review of the resident's Medication Administration Record confirmed that both medications were given as prescribed. Additionally, pharmacy consultant drug regimen reviews over several months did not include recommendations regarding the use of buspirone or escitalopram. During an interview, the DON stated she was unaware of the concurrent use of these medications for the same indication and acknowledged that this could be considered a duplication of therapy. Facility policy specified that psychotropic medications should not be given in excessive dosages.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications and biologicals. In one medication room, two expired containers of Lisinopril labeled for a resident with hypertension were found on a shelf, despite the resident still being present in the facility and having received new medications from the pharmacy. Staff interviews revealed uncertainty about who was responsible for removing expired medications, and the expired drugs had not been properly disposed of as required by facility policy. In another instance, a sealed, unopened box of Semaglutide, which requires refrigeration, was found stored at room temperature in a medication cart for a resident with Type 2 Diabetes Mellitus and diabetic neuropathy. The medication box was clearly labeled to be refrigerated, but staff confirmed it had not been stored correctly and could not determine how long it had been at room temperature. The responsibility for ensuring proper storage upon arrival from the pharmacy was not clearly assigned or followed. Additionally, an opened bottle of saline nasal spray was found in a medication cart, labeled only with a resident's first initial and last name handwritten in marker, lacking other required identifying information. Staff acknowledged that the labeling was insufficient, especially given the commonality of the name, and could not confirm the medication was intended for the correct resident. The facility's policy and staff interviews confirmed that medications should be properly labeled and stored to prevent errors.
Failure to Provide Kosher Diet for Resident with Religious Dietary Needs
Penalty
Summary
The facility failed to provide a resident with a no pork Kosher diet as required by her religious and cultural preferences for the first five days following her admission. Despite documentation in the admission record, order summary, and care plan indicating the need for a no pork Kosher diet, the resident continued to receive meals containing pork products, such as bacon, and her tray card only listed pork as a dislike rather than specifying a Kosher diet. The resident reported that when she received bacon, staff simply removed it from her plate, but this did not address her concerns about cross-contamination, as the bacon juices had touched other food items, making them inedible according to her dietary laws. Interviews with the dietary supervisor and dietician revealed a lack of knowledge and experience with Kosher diets among staff, and the facility did not have a policy for providing specialized diets. The dietary supervisor acknowledged that he was unaware of the full requirements of a Kosher diet and that the resident was the first to request such a diet during his tenure. The dietician confirmed that she was not contacted for guidance after the resident's admission, and the facility's process for updating diet orders did not ensure timely or accurate implementation of the resident's religious dietary needs.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to consistently sanitize her hands between glove changes while providing wound care to a resident. The LVN was observed changing gloves multiple times during the wound care process, including after moving from dirty to clean areas and after touching environmental surfaces such as the bedside table and trash can, but did not perform hand hygiene between each glove change. The LVN later acknowledged during an interview that she did not sanitize her hands as required, attributing it to forgetting, and recognized that this could result in contamination during the glove changing process. The resident involved had multiple complex wounds, including a stage 3 pressure ulcer, a stage 4 pressure ulcer, and an unstageable pressure ulcer, with a care plan and physician orders specifying wound care procedures. The facility's policy and the LVN's competency checklist both required hand hygiene before donning gloves and after removing gloves. The Director of Nursing confirmed that the LVN should have sanitized her hands between glove changes and that failure to do so could result in the spread of germs.
Failure to Maintain Safe Wheelchair Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically regarding a loaner wheelchair provided to a resident admitted for rehabilitation following a hip replacement. The resident, who had a history of femur fracture, repeated falls, and unsteadiness, reported that the right brake on her wheelchair was broken and did not fully engage, causing the wheelchair to move slightly during transfers. The resident communicated this issue to therapy staff, who attempted to address it but lacked the necessary tools and subsequently reported it to the Director of Rehabilitation (DOR) the following day. Observation confirmed that the right-side brake did not provide complete braking function. Interviews with therapy staff and the DOR revealed that the facility did not have a specific policy for wheelchair maintenance and relied on the general facility maintenance policy. The DOR and therapy staff acknowledged the issue after it was reported and described the process for submitting maintenance requests. The facility's policy stated that all equipment should be maintained in good working order to ensure safety, but the lack of a specific wheelchair maintenance protocol contributed to the delay in addressing the malfunctioning brake.
Failure to Provide Physician-Ordered Fortified Meal Plan
Penalty
Summary
The facility failed to provide a fortified meal plan (FMP) as ordered by the physician and dietician for one resident with significant medical needs, including vascular dementia, cerebral infarction, and chronic kidney disease. The resident was assessed as having severe cognitive impairment and was prescribed a therapeutic diet, specifically a FMP, due to nutritional concerns and a history of weight loss and low albumin levels. Despite these orders, the resident's meal ticket did not reflect the FMP requirement, and staff were not alerted to provide the necessary fortified meals. Observations and interviews revealed that the nursing and dietary staff relied on the meal ticket to guide meal preparation and serving. The LVN and ADON both confirmed that the absence of the FMP notation on the meal ticket meant staff were unaware of the need to provide extra calories, fats, and carbohydrates as part of the resident's meal. The Food Service Manager acknowledged receiving the FMP order and noted that the dietary database indicated the resident required a FMP, but could not explain why the meal ticket failed to include this information. As a result, the resident was not served meals in accordance with the physician's and dietician's orders. The facility's policy requires that therapeutic diets be provided as ordered by the physician and according to the service plan. However, the breakdown in communication and failure to update the meal ticket system led to the resident not receiving the prescribed fortified meal plan over an extended period. This deficiency was identified through record review, staff interviews, and direct observation of meal service.
Incomplete Documentation of Wound Care in LTC Facility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of wound care dressing changes. The Treatment Administration Record (TAR) for the resident showed missing entries on several dates, indicating that wound care was not documented as required. Interviews with the resident's charge nurse and another nurse revealed that they provided the wound care but forgot to document it due to being busy or because the resident preferred care from a specific nurse. This lack of documentation was acknowledged by the Director of Nursing as a basic nursing responsibility that was not fulfilled. The resident involved was an elderly male with a history of cellulitis, abnormal gait, cerebral infarction, type 2 diabetes, and edema. He had multiple pressure ulcers and required daily wound care as per physician orders. Despite receiving the necessary wound care, the failure to document these treatments on the specified dates could lead to improper wound care due to a lack of communication among the care team. The facility's policy mandates that all skilled services and changes in the resident's condition be documented, which was not adhered to in this case.
Deficiency in Pressure Ulcer Management Due to Missed Wound Care
Penalty
Summary
The facility failed to provide necessary wound care treatment to two residents, leading to a deficiency in pressure ulcer management. For one resident, the nursing staff did not administer wound care on two separate occasions, despite physician orders specifying daily treatment for multiple pressure ulcers. The resident's medical history included conditions such as cellulitis, diabetes, and cerebral infarction, which necessitated diligent wound care to prevent complications. The charge nurse admitted to being too busy to provide the care and failing to communicate the need for wound care to the evening shift nurses. Another resident did not receive wound care on a specific day because the wound care nurse could not locate the resident within the facility. Although the nurse documented the need for care in the 24-hour nursing shift report, a lack of communication resulted in the resident not receiving the prescribed treatment. This resident had a diabetic ulcer on the right toe, and the physician's orders required daily wound care to prevent infection. Interviews with the Director of Nursing and other staff confirmed that the facility's policy required daily wound care to prevent infection and promote healing. However, due to staff oversight and communication failures, the residents did not receive the necessary care as ordered. Although no immediate negative effects were observed, the deficiency highlighted the risk of potential wound infections if proper care was not consistently provided.
Deficient Care Planning for Resident's Comprehensive Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is a deficiency in meeting the resident's medical, nursing, and psychosocial needs. The care plan did not address the resident's activities of daily living (ADL) needs, indwelling catheter use, various diagnoses and treatments, dietary needs, therapy, and discharge planning. This oversight was identified during a review of the resident's records and interviews with facility staff. The resident in question was admitted with multiple complex medical conditions, including acute kidney failure, dysphagia, cognitive communication deficit, chronic obstructive pulmonary disease, chronic kidney disease, atherosclerotic heart disease, dementia, hypothyroidism, hyperlipidemia, depression, post-traumatic stress disorder, hypertension, angina pectoris, muscle weakness, benign prostatic hyperplasia, history of falls, and urine retention. The resident required a mechanically altered diet and had a history of falls, necessitating rehabilitation and strengthening. Despite these needs, the care plan only included focus areas such as code status, activity involvement, and a fall incident, without addressing the comprehensive needs identified in the resident's assessment. Interviews with facility staff revealed a lack of clarity and responsibility in the care planning process. The MDS Nurse stated that care plans were completed by the interdisciplinary team (IDT) within seven days of the MDS assessment, but did not personally develop or modify care plans. The LVN involved only completed specific portions related to falls and weights, and was not familiar with the resident. The DON indicated that the MDS Nurse was responsible for ensuring all necessary areas were included in the care plan, but this was not done. The Administrator acknowledged that inaccuracies in care plans could lead to unmet resident needs, highlighting a systemic issue in the facility's care planning process.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to its residents, specifically failing to administer Carvedilol to a resident as per the physician's orders. The resident, who was admitted with diagnoses including acute kidney failure, atherosclerotic heart disease, hypertension, and angina pectoris, did not receive the prescribed medication for hypertension. The resident's care plan did not include a focus or interventions for hypertension, and the medication administration record indicated a discrepancy in the administration of Carvedilol. Interviews revealed that the Director of Nursing (DON) believed the medication was held due to best practice, despite the absence of specific parameters in the physician's order. The physician expected nurses to apply parameters to the order, but this was not done. The medication aide (MA) and registered nurse (RN) involved did not recall specific details about the administration or parameters for the medication. The facility's policy required immediate implementation and follow-up of physician's orders, which was not adhered to in this case.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding the documentation of heart rate (HR). On 10/20/24, a Licensed Vocational Nurse (LVN) documented a heart rate of 2 beats per minute (bpm) for a resident, which was likely an error. This inaccurate documentation was not identified or corrected by the Director of Nursing (DON) or Assistant Directors of Nursing (ADONs), who were responsible for ensuring the accuracy of resident records. The resident in question had a history of acute kidney failure, atherosclerotic heart disease, hypertension, and angina pectoris, and was on medication for hypertension, which required monitoring of blood pressure and pulse. The facility's policy on charting and documentation requires that all services provided to the resident and any changes in their condition be documented accurately and objectively. However, the failure to ensure the resident's electronic medical record (EMR) reflected an accurate heart rate could potentially place residents at risk for improper care. Interviews with the DON and the LVN involved revealed that the error was not remembered by the LVN, and the DON acknowledged the expectation for accurate medical records, highlighting a lapse in adherence to the facility's documentation policies.
Failure to Implement Discharge Medication Orders
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in a delay in medication administration. The deficiency involved the failure to transcribe and implement the discharge medication orders for a resident who was admitted to the facility from a hospital. The resident, who had multiple medical conditions including COVID-19, pneumonia, diabetes, and atrial fibrillation, did not receive his prescribed medications for four to five days after admission. This delay was due to the facility's inability to obtain the discharge medication list from the hospital in a timely manner. Upon the resident's admission, the admitting nurse discovered that the discharge paperwork was incomplete, lacking the medication list. Despite multiple attempts to contact the hospital and request the necessary documents, the facility staff faced issues with fax machine connectivity and communication breakdowns. The ADON was informed of the situation and attempted to resolve it by contacting the hospital's house supervisor and eventually receiving the medication list via email. However, due to assumptions and miscommunications between the ADON and the DON, the medication orders were not transcribed or implemented until several days later. Interviews with facility staff revealed a lack of follow-up and coordination in addressing the missing medication orders. The ADON assumed the DON would handle the situation, while the DON believed the issue was resolved. The resident expressed concerns about the delay in receiving medications, although he did not experience any adverse effects. The NP and DON acknowledged the potential risks of the delay, but fortunately, the resident remained stable during this period. The facility's policy required immediate initiation of treatments and medication orders upon admission, which was not adhered to in this case.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in several rooms and a hall on the third floor. Specifically, the facility did not repair wall scrapes behind resident beds in two rooms, did not replace burnt-out light bulbs in another room, and did not address water damage between two rooms. These deficiencies were observed during a tour with the Maintenance Director and the Administrator. The Maintenance Director was unaware of any work orders for the wall repairs, and the burnt-out light bulbs had been an issue for 4 to 5 days according to a resident. The Administrator acknowledged the issues but noted that the staff could report maintenance problems electronically. Additionally, the wall between two rooms showed signs of water infiltration, with missing paint and an open area where the ceiling tiles and wall meet. The Administrator confirmed awareness of the water damage, which had been present for a few weeks, and mentioned ongoing problems with rain and air conditioning condensation. The facility's preventative maintenance policy requires regular inspections by the Maintenance Director, but these issues were not addressed in a timely manner, leading to an environment that is unpleasant, unsanitary, and unsafe for residents.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that residents received food at a safe and appetizing temperature. Resident #1, who has cerebral palsy, generalized anxiety disorder, and hypertension, reported receiving cold meals on multiple occasions. Despite sometimes being offered to have the meals reheated, the resident often ate the food cold if he was hungry enough. Similarly, Resident #77, with atherosclerotic heart disease, hypothyroidism, and hyperlipidemia, reported that most of his meals in the past three weeks were cold, and he did not like eating them that way. Both residents have intact cognition as indicated by their BIMS scores. Observations and interviews with staff revealed that food trays were placed on top of the food cart, which contributed to the food being served at lower temperatures than recommended. Temperature checks of the food confirmed that the sausage and eggs were below the FDA Food Code 2022 recommended temperatures for hot foods. Staff members, including a CNA and an LVN, acknowledged the issue and mentioned that they sometimes reheated the meals or replaced them when residents complained. The Activity Director also confirmed that residents had been voicing concerns about cold food for several months.
Food Service Safety Violations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen. Cook A was observed preparing food without a facial hair restraint, despite having facial hair approximately 1/4 to 1/2 inch in length. The Dietary Manager (DM) acknowledged that Cook A should have worn a facial hair restraint. Additionally, the DM was observed wearing a watch while engaged in food preparation, which is against food safety regulations. The DM admitted to knowing the rule but wore the watch to assist the short-staffed kitchen team during lunch preparation. In the walk-in cooler, an opened quart of heavy whipping cream was found without a label or use-by date, and a container of thickened dietary beverage was past its use-by date. The DM stated that it was the staff's responsibility to ensure food items were sealed, labeled, and dated, and admitted to not knowing when the heavy cream was opened. In the dry storage room, two small plastic bowls filled with crispy rice cereal were not sealed, labeled, or dated, and a #10 can of tomatoes was found on the floor. The DM acknowledged these lapses, stating that the cereal should have been properly sealed and dated, and the can of tomatoes should not have been on the floor. The tabletop can opener in the kitchen was found covered in sticky black and brown grime, including the blade, plastic insert, and base. The DM admitted that the can opener was in need of cleaning and sanitizing and that it was the cooks' responsibility to keep it clean. The facility's policy and the U.S. FDA Food Code were reviewed, confirming the requirements for personal hygiene, food storage, and equipment cleanliness, all of which were not met in this instance.
Failure to Secure Medications Properly
Penalty
Summary
The facility failed to ensure medications were not left on a resident's bedside table. Specifically, a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1% were observed on the bedside table of a resident who did not have a physician's order to self-administer medications. The resident, who had intact cognition as indicated by a BIMS score of 15, stated that he had purchased the over-the-counter medications from an online store and had them on his bedside table since his admission. No self-medication assessment had been conducted for this resident. Interviews with facility staff, including a CNA, an LVN, and the DON, confirmed that the medications had been on the resident's bedside table for an extended period. The LVN mentioned that the resident became upset when asked to move the medications to the medication cart for safekeeping. The DON acknowledged that no medication should be left on any resident's bedside table without a self-medication assessment and a signed physician order, as this could risk the resident taking more than the prescribed dosage. The facility's policy requires a signed physician order for residents who self-administer medications.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by an incident involving a registered nurse (RN) administering medications to a resident. The RN, while administering eye drops to a resident, touched various contaminated objects in the resident's environment, including a light fixture pull cord, power plug, and bed remote, without changing gloves or sanitizing hands before touching the resident's face and eyes. This action was observed during a medication administration process and confirmed by the RN during an interview, who acknowledged the environment around the resident was considered contaminated and that she should have changed her gloves and sanitized her hands before proceeding with the medication administration. The resident involved had multiple diagnoses, including dysphagia, insomnia, hemiplegia, cerebral infarction, hypertension, and vascular dementia, and required extensive assistance to total care. The RN had received infection control training within the year and had passed competency for hand hygiene and infection control during medication administration. The Director of Nursing (DON) confirmed that the staff should have changed gloves after touching the environment and before touching the resident's eyes, and that infection control training was provided yearly and as needed. The facility's policy on hand hygiene required the use of an alcohol-based hand rub before handling medications and after contact with objects in the immediate vicinity of the resident.
Failure to Update Care Plan for Resident's Self-Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #4, who was responsible for his own colostomy care. Despite the resident having a BIMS score of 15, indicating intact cognition, and a physician's order to change the colostomy bag every three days and as needed, the care plan did not reflect that the resident was performing his own colostomy care. This oversight was confirmed through interviews with the LVN, the MDS nurse, and the DON, all of whom were unaware that the resident was managing his own colostomy care. The deficiency was identified during a review of Resident #4's records and interviews with staff and the resident himself. The MDS nurse, responsible for completing care plans, admitted to being unaware of the resident's self-care activities, which led to the care plan not being updated. The DON also acknowledged the risk posed by the lack of an updated care plan, as it could result in the care team not being fully informed about the resident's needs. The facility's policy on comprehensive care planning, dated August 2017, mandates the development and implementation of a person-centered care plan that includes measurable objectives and timeframes, which was not adhered to in this case.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly, as observed during a tour of the garbage disposal area. The garbage disposal unit, which had a top attached lid measuring 40x20 inches, was left open, exposing stacked bags of garbage inside. The Food Service Director confirmed that the lid should have remained closed to prevent pests from entering the facility. The Administrator also stated that the garbage lid was to remain closed at all times to prevent rodent intrusion. The facility's policy, dated 05/2007, indicated that food waste should be disposed of in garbage disposal or covered waste cans.
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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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