Pinecrest Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Lufkin, Texas.
- Location
- 1302 Tom Temple Dr, Lufkin, Texas 75904
- CMS Provider Number
- 676124
- Inspections on file
- 24
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pinecrest Retirement Community during CMS and state inspections, most recent first.
Two CNAs failed to follow proper infection control practices during incontinent care for a resident with chronic conditions, cognitive impairment, continuous incontinence, and a documented UTI. Surveyors observed both CNAs enter the resident’s room without performing hand hygiene, don gloves, and complete the entire perineal care procedure—including handling a urine-soiled brief, cleansing the perineal and rectal areas, applying barrier ointment, and adjusting clothing—without changing gloves between dirty and clean tasks. In interviews, the CNAs reported they believed gloves only needed to be changed if visibly soiled with feces, despite having prior skills check-offs in perineal care and infection control, while facility leadership confirmed that these actions were inconsistent with established hand hygiene and glove-change requirements.
A resident on contact isolation and Enhanced Barrier Precautions for an MDRO, with chronic systolic heart failure, anemia, osteoporosis, moderate cognitive impairment, and total urinary/bowel incontinence, received incontinent care during which two CNAs failed to follow the facility’s infection control policies. They entered the room with a posted contact precautions sign, did not perform hand hygiene before care, wore only gloves without gowns, and did not change gloves when moving from cleaning soiled areas to handling clean briefs and applying barrier ointment. Interviews showed both CNAs misunderstood glove use and did not attend to the isolation signage, despite prior competency check-offs, while leadership confirmed that facility policy requires gowns and gloves for high-contact care under EBP, glove changes between dirty and clean tasks, and hand hygiene before, during, and after resident contact.
Dietary staff did not consistently test or log dish machine sanitizing temperatures, and food was served without verifying proper holding temperatures in the main and satellite kitchens. Staff also used improper food handling techniques, such as serving food with gloved hands after touching other surfaces, and failed to follow facility policies for temperature monitoring and utensil use.
The facility failed to maintain sanitary conditions in the kitchen, with undated and expired soda syrup concentrates connected to the drink dispenser and improperly labeled and expired foods in the freezer. The Dining Director acknowledged the oversight and the need for proper labeling and removal of expired items.
The facility failed to ensure that three dietary staff members had current food handler certifications, which could place residents at risk of food-borne illness. The Dining Director and Administrator acknowledged the oversight, and the facility's policy requires that all personnel maintain current certifications in their personnel records.
The facility failed to ensure an accurate MDS assessment for a resident, who was incorrectly coded as having restraints. The error was identified during an audit, and the MDS assessment was subsequently modified to reflect the accurate status of the resident.
A facility failed to develop and implement a baseline care plan within 48 hours for a resident admitted with a femur fracture. The care plan was completed 18 days late, and the resident's family was not provided with a summary. Staff interviews revealed inconsistencies in managing the responsibility for completing baseline care plans, leading to delays and potential care delivery issues.
A resident with severe cognitive impairment and a history of falls was left unattended in a sit-to-stand lift by a CNA, resulting in a fall. The CNA left the room to retrieve supplies, and upon return, found the resident on the floor. The resident was assessed for injuries, and none were found. The CNA was suspended and later terminated, and the facility conducted in-service training on proper lift use.
A facility failed to ensure safe and sanitary storage of a resident's food items, leading to the presence of expired cheese sticks, prune juice, and nutritional shakes in the resident's personal refrigerator. Staff inconsistently checked for expired foods, focusing mainly on temperature logs, despite the facility's policy requiring the disposal of opened or dated items after three days.
A CNA failed to sanitize or wash hands between glove changes while providing incontinent care to a resident with severe cognitive impairment and incontinence. This lapse in infection control protocol was observed and confirmed through interviews, highlighting a deficiency in the facility's infection prevention and control program.
Failure to Ensure CNA Competency in Hand Hygiene and Glove Use During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that certified nurse aides (CNAs) possessed and demonstrated appropriate infection control competencies, specifically hand hygiene and glove use, during incontinent care. Surveyors observed two CNAs (A and B) enter the room of Resident #8 without performing hand hygiene and immediately don gloves. They then conducted the entire incontinent care procedure without changing gloves, despite handling soiled items and then moving to clean tasks and clean items. Resident #8 had been recently admitted with diagnoses including chronic systolic heart failure, anemia, and osteoporosis. A Significant Change MDS assessment documented moderate cognitive impairment with a BIMS score of 10, a need for partial/moderate assistance with toileting hygiene, and continuous urinary and bowel incontinence. Her care plan, revised shortly before the observation, identified a UTI and included interventions to check for incontinence at least every two hours, indicating ongoing incontinence management needs. During interviews, both CNAs acknowledged they had received skills check-offs on hire, including perineal care and infection control, but each stated they believed they could continue using the same gloves as long as they were not visibly soiled with feces. They both recognized, when questioned, that gloves should be changed after handling dirty items and that failure to do so could result in cross-contamination. Facility leadership, including the ADON/IP, DON, and Administrator, stated that staff were trained on infection control, that hand hygiene should be performed before, during, and after care, and that gloves should be changed between dirty and clean tasks, confirming that the observed practices by CNAs A and B did not comply with facility policy and competency expectations for infection control.
Failure to Follow Contact Precautions and Hand Hygiene During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program for a resident on contact precautions and Enhanced Barrier Precautions (EBP). The resident was an older adult admitted with chronic systolic heart failure, anemia, and osteoporosis, and had active physician orders for EBP related to a multidrug-resistant organism (MDRO) and an abnormal urinalysis, with contact isolation precautions in place. Her care plan documented contact isolation precautions and the need to follow the facility’s isolation policy. A Significant Change MDS showed she had moderate cognitive impairment and was always incontinent of bowel and bladder, requiring partial to moderate assistance with toileting hygiene. During an observed episode of incontinent care, two CNAs entered the resident’s room, which had a contact precautions sign posted and contained PPE supplies including gowns, N95 masks, face shields, and biohazard bags. Neither CNA performed hand hygiene before starting care, and both donned only gloves without gowns despite the contact precautions order. One CNA pulled down the resident’s pants and brief and performed perineal cleansing of the inner thighs and vaginal area, while the other CNA rolled the resident, cleansed the rectal area, removed the soiled brief, and then placed a clean brief under the resident and applied barrier ointment without changing gloves between handling soiled items and clean items. One CNA washed her hands only after removing gloves at the end of care, and the other CNA removed gloves and discarded them without documented hand hygiene. In subsequent interviews, both CNAs acknowledged they did not pay attention to the contact precautions sign, did not wear gowns, did not perform hand hygiene before care, and did not change gloves when moving from dirty to clean tasks, stating they believed gloves could be worn throughout care if not visibly soiled with feces. They each had prior competency checklists indicating they had been observed performing perineal care and infection control. The ADON, serving as the Infection Preventionist, and the DON described facility policies and expectations that staff wear gowns and gloves for residents on contact precautions or EBP during high-contact care such as changing briefs, perform hand hygiene before, during, and after care, and change gloves between dirty and clean tasks, consistent with the facility’s written policies on Enhanced Barrier Precautions, Isolation/Transmission-Based Precautions, and Handwashing/Hand Hygiene.
Failure to Maintain Sanitary Food Storage, Preparation, and Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the main kitchen and all three satellite kitchens. Dietary staff did not accurately test or log dish machine temperatures for hot water sanitizing on multiple occasions, and there were missing entries for several meal periods. Observations revealed that the dish machine temperatures were below required sanitizing levels, and staff did not consistently communicate these discrepancies to management. Additionally, dishware and silverware were washed and returned to satellite kitchens without proper temperature verification, and the facility's own policy required documentation of these temperatures at each meal period. Food service staff did not consistently take or record holding temperatures before serving food to residents. On several occasions, food was served without verifying that it was at the appropriate holding temperature, including both main and alternate food items. In some cases, food items such as chicken strips, French fries, and pureed meals were found to be below the required serving temperatures, yet were still served to residents. Staff interviews confirmed that temperatures were not always checked or recorded as required by facility policy. Sanitary food handling practices were also not followed. Staff were observed using gloved hands to serve food items after touching other surfaces and utensils, without changing gloves between tasks. This included handling rolls, French fries, chicken strips, and onion rings. Staff demonstrated a lack of understanding regarding the need to change gloves and use utensils for serving food, as required by facility policy. These failures in food storage, preparation, temperature monitoring, and handling could place residents at risk of foodborne illness.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the main kitchen. During an observation, six containers of concentrated soda syrup connected to the drink dispenser were found without documented opened dates, and three containers were expired. The Dining Director, who had been working at the facility for two months, acknowledged the oversight and stated that he was responsible for discarding expired items. Additionally, the freezer contained improperly labeled and expired foods, including a clear zip lock bag of frozen chicken with no use-by date, a bag of beef stock with an expired use-by date, and an unlabeled bag of frozen fish. The Dining Director admitted responsibility for training the dietary staff and ensuring proper labeling and removal of expired items. Interviews with the Dining Director and the Administrator confirmed that serving expired foods could cause illness and that it was the responsibility of the Dietary Director to ensure all expired food was removed from the kitchen. The facility's Food Safety and Quality Assurance Standards Manual indicated that expired foods must be discarded and not used or served. The Dining Director mentioned that an in-service training for dietary staff regarding labeling and removing expired items had begun, emphasizing the importance of all team members adhering to these standards.
Failure to Ensure Dietary Staff Had Current Food Handler Certifications
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, three dietary staff members (Dietary Staff D, E, and F) did not have current food handler's certificates while working in the facility's kitchen. This was discovered during a review of records and interviews conducted between 04/29/24 and 05/01/24. The Dining Director acknowledged that it was his responsibility to ensure all kitchen staff had current food handler certifications and admitted that the three employees did not have the necessary certifications. The Administrator also confirmed that she expected all dietary staff to have updated food handler certificates and receive training to prevent food-borne illness. The facility's policy requires that personnel who need a license, certification, or registration to perform their duties must present verification upon employment and maintain current certifications in their personnel records. The deficiency was identified through a review of 28 dietary staff members' food handler certificates, which revealed that Dietary Staff D, E, and F did not have current certifications. The Dining Director stated that he had spoken with the three employees, who confirmed they did not have current food handler certifications. The facility's policy mandates that employees present verification of required certifications to the Human Resources Director or designee prior to or upon employment and maintain current certifications in their personnel records. The failure to ensure that these dietary staff members had current food handler certifications could place all residents who consumed food prepared in the kitchen at risk of food-borne illness.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident, who was incorrectly coded as having restraints. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was documented as using physical restraints in bed, which was not the case. The Director of Nursing (DON) confirmed that the facility was restraint-free and that no residents, including the one in question, had restraints. The MDS Coordinator admitted to accidentally checking the restraint box on the MDS assessment and stated that she had modified the assessment to correct the error after it was brought to her attention. The Regional MDS Coordinator, who audits the facility's MDS assessments quarterly, also confirmed that the facility was restraint-free and that the incorrect coding should have been caught by the MDS Coordinator. The Administrator acknowledged the error and mentioned that the facility's policy requires all portions of the MDS to be certified for accuracy by the responsible staff. The incorrect coding was identified during an audit, and the MDS assessment was subsequently modified to reflect the accurate status of the resident.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by regulations. Specifically, a male resident admitted with a diagnosis of aftercare for a femur fracture did not have his baseline care plan completed until 18 days after admission. Additionally, the resident's family was not provided with a summary of the baseline care plan. Interviews with staff, including an LVN, MDS Coordinator, DON, and the Administrator, revealed that the responsibility for completing the baseline care plans was not consistently managed, leading to delays and potential care delivery issues. The LVN responsible for completing the baseline care plans admitted to sometimes falling behind, while the MDS Coordinator and DON confirmed that the admitting nurse or weekend supervisor should complete the care plans within the required timeframe. The Administrator acknowledged that the previous system for completing baseline care plans was not effective and that the current process would be reviewed for compliance. The facility's policy, dated December 2016, mandates that a baseline care plan be developed within 48 hours of admission and that a summary be provided to the resident or their representative, which was not adhered to in this case.
Inadequate Supervision During Transfer
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who required substantial assistance with transfers. On the specified date, a CNA left the resident standing in a sit-to-stand lift unattended to retrieve supplies, resulting in the resident falling. The resident had a history of falls, muscle weakness, and severe cognitive impairment, necessitating careful supervision during transfers. The incident occurred when the CNA noticed the resident was wet and used the sit-to-stand lift to provide care. Upon realizing that wipes were needed, the CNA left the resident unattended in the lift to search for wipes in another room and at the nurse's station. The CNA returned to find the resident on the floor, having fallen from the lift. The resident was assessed for injuries, and none were found. Interviews with staff revealed that the facility's policy required 1-2 person assistance for using the sit-to-stand lift, depending on the resident's condition. The CNA involved was suspended and later terminated. The facility conducted in-service training on the proper use of lifts and fitting slings correctly following the incident. Observations and interviews confirmed that staff were aware of the need for proper supervision and assistance during transfers, but the incident highlighted a lapse in following these protocols.
Failure to Ensure Safe and Sanitary Storage of Resident's Food Items
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of a resident's food items, specifically in the personal refrigerator of a resident. The resident, a male with diagnoses including scoliosis, chronic pain, and anemia, had expired food items in his refrigerator, including cheese sticks, prune juice, and nutritional shakes. Despite the resident's efforts to keep the refrigerator clean and monitor temperatures, expired items were found during an inspection. Staff members, including LVNs and CNAs, were responsible for checking the personal refrigerators but failed to consistently check for expired foods, focusing instead on temperature logs. This inconsistency led to the presence of expired food items in the resident's refrigerator. Interviews with various staff members revealed that while some staff checked the personal refrigerators for expired foods, others only checked temperature logs. The facility's policy required that all opened or dated items be discarded after three days, but this was not consistently enforced. The ADON and DON were supposed to make rounds to ensure compliance, but expired items were still found in the resident's refrigerator. The facility's administration acknowledged that residents were responsible for their personal refrigerators, but nursing staff were expected to ensure compliance with the policy, which was not effectively done in this case.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of CNA A during the provision of incontinent care to Resident #6. CNA A did not sanitize or wash hands between glove changes, which is a critical step in preventing the transmission of infections. During the care, CNA A removed gloves and applied new ones without performing hand hygiene, despite being trained on proper infection control protocols. This lapse was observed during an incident where CNA A and CNA B were providing care to Resident #6, who has severe cognitive impairment and is always incontinent of bowel and bladder. Resident #6, who has diagnoses including dementia, anemia, and hypertension, required substantial assistance with activities of daily living. The care plan for Resident #6 included cleaning the peri-area with each incontinence episode. Despite this, CNA A failed to follow proper hand hygiene protocols, which was confirmed during interviews with CNA A, the ADON, and the Administrator. The facility's policy on hand hygiene, which emphasizes the importance of hand washing to prevent the spread of infections, was not adhered to in this instance.
Latest citations in Texas
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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