Pleasant Manor Healthcare Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Waxahachie, Texas.
- Location
- 3650 S Ih 35 E, Waxahachie, Texas 75165
- CMS Provider Number
- 675889
- Inspections on file
- 30
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Pleasant Manor Healthcare Rehabilitation during CMS and state inspections, most recent first.
Failure to Obtain Ordered Daily Weights: A resident with HF, HTN, COPD, and depression did not receive ordered daily weights consistently, despite a care plan intervention to obtain weight as ordered and a physician order for daily weights with MD notification for a 3-lb gain in 24 hours. The resident stated staff sometimes weighed her and sometimes did not, and facility leadership gave differing accounts of who was responsible for the task.
Failure to Ensure Ordered Zofran Was Available and Properly Administered A resident with MI, chronic respiratory failure, weakness, and a BIMS of 15 had an order for Zofran 4 mg QID for nausea, but the medication was not delivered from the pharmacy and doses were still documented as given. The resident said he had been waiting for the medication for weeks and was told he was receiving half tablets from other residents’ supply. A med aide said she signed the dose out without seeing it given, and an RN said she never administered it and had not contacted the pharmacy about the missing medication. A second resident with dementia and severe cognitive impairment had a PRN Zofran order, but 29 tablets were missing from her supply while no doses were documented on the MAR. Interviews confirmed the facility was responsible for obtaining the medication, residents should not share meds, and the facility policy required timely receipt and accurate documentation of medications.
Failure to Employ a Qualified Full-Time Social Worker: The facility’s Licensed Social Worker did not hold a current social work license, even though the job description required an LSW or higher-level license. HR confirmed the USW was hired without current licensure, and the ADM stated she was used as the facility’s social worker, represented herself that way to residents and families, signed psychosocial assessments, and participated in the IDT in that role.
Call lights were left out of reach for two residents with significant cognitive and functional impairment. One resident with Alzheimer's disease, dementia, repeated falls, and dependence for many ADLs was observed in bed with the call light hanging out of reach. Another resident with dementia, gait and mobility problems, and fall risk had the call light hanging over the bed rail and on the floor, and she could not reach it when asked. Staff stated call lights should always be within reach, and the facility policy required placing the call device within the resident's reach before leaving the room.
Failure to Reassess and Report Low BP: A resident with CHF, Alzheimer's disease, and severe cognitive impairment had a BP of 94/39 mmHg, causing a CMA to hold valsartan for parameters below the ordered limits. No repeat BP was obtained, no low BP note was documented in the progress note, and the event was not reported as a change in condition to hospice, despite staff stating that abnormal vital signs should be rechecked, documented, and communicated to the RN/MD or hospice provider.
Broken Foyer Skylights Left in Disrepair: The facility failed to maintain a safe, clean, comfortable, and homelike environment when 2 of 4 foyer skylights were found broken with visible holes and shards covered by tape. The LM, ADM, and FMD gave differing accounts of when the damage occurred and when repairs were initiated, and the FMD stated he did not enter the issue into TELS because he called the roofing company directly.
Failure to attempt a GDR for a resident receiving Quetiapine for depression. The resident had severe cognitive impairment, dementia, aphasia, dysphagia, and weakness, and records showed ongoing antipsychotic use without any documented GDR or clinical contraindication. A consultant pharmacist recommended a trial dose reduction, but the physician response was left blank and staff interviews showed the recommendation was not addressed.
A facility failed to fully care plan a resident's ongoing verbal outbursts and failed to update another resident's care plan after disposable dinnerware was no longer needed. Staff observed the first resident yelling out, grabbing at unseen objects, and being moved away from others when she yelled, while interviews confirmed the behavior was longstanding but not specifically addressed in the care plan. For the second resident, records showed prior dish-washing behaviors had stopped and a note stated foam plates were no longer needed, yet he was still served meals on a foam plate.
Failure to Provide Needed Fingernail Care: A resident with DM, dementia, myopathy, and severe cognitive impairment required partial/moderate help with personal hygiene, but his fingernails were observed long, jagged, and dirty. The resident said nurses refused to cut them, while CNA and RN interviews showed confusion about who was responsible for nail care and that the resident was not on a scheduled nail-trimming date.
A resident with glaucoma, impaired cognition, weakness, and ADL assistance needs was observed shaving herself with a disposable razor and mirror without staff supervision. She later showed surveyors a bag in her purse containing about 5 disposable razors. Staff said they were unaware she had the razors, had not seen her shave before, and daily room checks were missed.
Laundry Room Water Leak Not Addressed: A plumbing line behind the washer in the facility’s only laundry room was observed leaking water onto the floor and into the dirty laundry area, with cloths and blankets placed to soak up the water. Staff reported the leak had been ongoing for months, the FMD had tried Flex Seal spray, and the maintenance logbook and Tels work order report did not document the issue.
A medication cart was left unlocked and unattended in a hallway, with keys on top, while a medication aide was sidetracked. Additionally, the facility's medication storage room was found unlocked and unattended. The facility's policy requires all drugs and biologicals to be stored in locked compartments, accessible only to authorized personnel.
The facility failed to discard expired pantry items in its kitchen, as observed during a survey. Several containers of spices were found with expired dates, which were not discarded as required by food safety standards. Interviews revealed that employees were responsible for labeling food items, but the facility did not adhere to the FDA 2022 Food Code, which mandates discarding food held beyond its expiration date.
A facility failed to ensure a resident's dignity during feeding assistance when an SLP stood over the resident while assisting with eating. The resident, who had Alzheimer's and other health issues, was being evaluated for weight loss. The SLP was unsure about proper feeding assistance protocol, and the facility's training materials lacked guidance on maintaining resident dignity by sitting during assistance.
A facility failed to coordinate PASARR assessments for a resident with severe cognitive impairment and mental health diagnoses. The SW did not assess the resident for PASARR services, and the MDSC did not refer the resident for a Level II PASARR Evaluation. The resident's medical records lacked a P-2 or referral to the LIDDA, and the MDSC failed to retrieve the correct P-1 document indicating a mental illness. This oversight placed residents at risk for exclusion from PASARR services.
A facility failed to include interventions for elopement in a care plan for a resident with severe cognitive impairment and a high elopement risk score. Despite the facility's policy requiring comprehensive care plans, the resident's plan lacked necessary interventions, placing them at risk. Staff interviews revealed a recent change in MDS personnel contributed to this oversight.
A facility failed to maintain clean oxygen equipment for a resident with respiratory issues by not placing the oxygen tubing in a bag when not in use. The resident, who was cognitively intact and had a history of respiratory conditions, expressed a preference for clean equipment. Staff interviews confirmed that the tubing should be changed weekly and bagged, as per physician's orders and facility policy.
A facility failed to monitor a resident's drug regimen by not obtaining a stop date for Cipro, an antibiotic prescribed for a UTI. The resident, with a history of neuromuscular dysfunction and other conditions, received 14 doses without a specified duration. Another antibiotic, Levofloxacin, was later prescribed, but Cipro was not discontinued. Staff interviews revealed a lack of adherence to protocols for obtaining stop dates, and the facility's policy on unnecessary drugs was not followed.
A facility failed to maintain proper infection control when two staff members did not perform hand hygiene between glove changes during peri care for a resident with incontinence. Despite training and policy requirements, this lapse occurred, risking cross-contamination and infection. The resident, with acute respiratory failure and COPD, required careful infection control due to incontinence.
Failure to Obtain Ordered Daily Weights
Penalty
Summary
The facility failed to ensure that Resident #13 received daily weights in accordance with the resident’s order, comprehensive care plan, and stated need for monitoring related to heart failure. Resident #13 was a cognitively intact female with diagnoses including heart failure, hypertension, chronic obstructive pulmonary disease, and depression. Her care plan included obtaining weight as ordered, and her physician order required daily weights with notification of the MD for a weight gain of 3 pounds or more in 24 hours. Record review showed multiple dates in February and March 2026 when no daily weight was documented for the resident, despite weights being recorded on some other dates. During interview, Resident #13 stated that staff sometimes obtained her weight and sometimes did not, and that weights were needed to monitor swelling in her legs because she had heart failure. The ADON stated charge nurses were responsible for obtaining daily weights and notifying the physician of weight variance, but did not know why the resident’s weight was not obtained daily. The CDON stated charge nurses were responsible for obtaining daily weights and that the DON and ADON were responsible for monitoring completion, while the ADM stated CNAs were responsible for daily weights for Resident #13. The facility policy stated residents are to receive appropriate treatment and services in accordance with a written plan of care.
Failure to Ensure Ordered Zofran Was Available and Properly Administered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring prescribed Zofran 4 mg was accurately acquired, received, dispensed, and administered for two residents. One resident, who had diagnoses including myocardial infarction, chronic respiratory failure, muscle weakness, difficulty walking, and a BIMS score of 15, had an order for Zofran 4 mg four times daily for nausea. His medication administration record showed multiple doses were documented as given even though the medication had not been delivered from the pharmacy, and he stated he had been waiting for the medication since the prior month and was receiving half tablets. He also stated he was told the medication came from other residents because the facility had plenty. Record review and interviews showed the medication was not in the building when staff documented it as administered. A medication aide stated she could not locate the resident’s Zofran in the cart and had signed it out as given because she was told by an RN to do so, although she did not actually see the medication administered. The RN stated she did not give the medication, did not pull it from the emergency cart, and knew the resident had not had any Zofran in the building because it had never been delivered from the pharmacy after being ordered. She also stated she had not contacted the pharmacy to ask why it was not delivered. The investigation found that another resident, who had dementia with a BIMS score of 02 and an order for Zofran 4 mg every 8 hours as needed, had 29 tablets missing from her supply, while her MAR showed no doses administered. Observation showed she had only one tablet left from the original 30-tablet supply. Interviews with hospice, pharmacy, the MD, and facility leadership confirmed that residents should receive their own medications, that the facility was responsible for ordering medications not covered by hospice, and that sharing medications was not appropriate. The facility also had a policy requiring timely receipt of medications and prompt reporting of discrepancies and omissions to the pharmacy.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility with 121 licensed beds failed to employ a qualified social worker on a full-time basis. Survey review showed the facility’s licensed capacity was 132 beds, and the all-staff list identified the USW as the Licensed Social Worker. The job description for the Social Worker position required current licensure as an LSW or higher-level license, and the USW signed that job description on 11/12/2024. Record review and interviews showed the USW did not hold a current social worker license through the Texas Behavioral Health Executive Council. An HR email dated 10/13/2025 documented that HR requested the USW’s social worker license, and the USW replied that she had not gotten it yet and would be testing on 12/8/2025. HR stated the USW was hired on 11/11/2024 and that she did not have a current license. The ADM stated he hired the USW, identified her as the qualified social worker for social services, and said she represented herself to residents, families, and staff as a social worker, signed psychosocial assessments as the social worker, and participated in the interdisciplinary team in that role. He also stated that when she failed her licensure exam in January 2025, he told her she had one more chance to pass before they would need to find a qualified candidate.
Call Lights Left Out of Reach for Two Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach. Resident #20, an 83-year-old female with diagnoses including Alzheimer's disease, repeated falls, lack of coordination, and dementia, had a quarterly MDS assessment showing a BIMS score of 00 and dependence for multiple ADLs. Her care plan identified communication problems related to TIAs, dementia, and difficulty hearing, and included interventions to keep the call light in reach and encourage use of the bell for assistance. During observation, she was lying in bed and her call light was hanging to the right side of the head of the bed, out of her reach. Resident #50 had diagnoses including dementia, abnormalities of gait and mobility, lack of coordination, hypertension, and muscle weakness. Her quarterly MDS assessment showed a BIMS score of 04 and need for supervision or assistance with several ADLs, while her care plan identified fall risk related to poor safety awareness and high-risk medication and included keeping the call light within reach. During observation and interview, her call light was hanging over the left side of the bed rail and on the floor, and she was unable to reach it when asked. Staff interviews showed that LVNs, CNAs, the CDON, and the ADM all stated that call lights should be within reach at all times and that staff entering resident rooms were responsible for ensuring this. The facility policy titled Call Light/Bell Policy stated that the call device should be placed within the resident's reach before leaving the room. Despite these expectations and policy, both residents were observed with call lights out of reach.
Failure to Reassess and Report Low Blood Pressure
Penalty
Summary
The facility failed to reassess, report, and document a change in condition for Resident #19 after a low blood pressure reading was obtained. Resident #19 was a [AGE]-year-old male admitted with congestive heart failure, Alzheimer's disease, and muscle weakness, and his BIMS evaluation reflected severely impaired cognition. On 01/30/2026 at 10:10 AM, his blood pressure was 94/39 mmHg sitting in the right arm, and the ordered Valsartan 320 mg was held by the medication aide because the blood pressure was below the medication parameters. No additional blood pressure readings were taken after the low reading, and no note of low blood pressure was documented in the resident's progress note. Interviews with staff reflected that abnormal vital signs were expected to be rechecked, reported to the charge nurse, and communicated to the physician or hospice provider when appropriate, but the low blood pressure event for Resident #19 was not reported as a change in condition to hospice on that date. The facility policy stated that when a CMA holds a blood pressure medication because parameters are low, the licensed nurse must be notified and intervene as appropriate, including rechecking vital signs and informing the physician or hospice provider.
Broken Foyer Skylights Left in Disrepair
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when 2 of 4 skylights in the foyer were found broken with visible holes and broken shards underneath tape that had been placed over the damage. During observation, the foyer skylights were noted to be in disrepair, and the condition was documented as having existed for an unknown amount of time. The report states that the broken skylights were visible from the facility front entrance area and that the condition could affect residents, staff, or visitors entering through the front doors. During interviews, the LM stated the skylights had broken due to wind and that he did not remember exactly when they broke, though he thought it was at the beginning of 2026. He also stated he was not sure when the maintenance director contacted a contractor to measure and replace them. The ADM stated the skylights had just been fixed and later said he could not find documentation showing the facility had reached out for the skylights to be repaired before the survey team arrived. The FMD stated he identified the broken skylights on Monday, contacted the roofing company, and that the company measured and installed new skylights on Wednesday. He also stated he did not enter the issue into the TELS system because he called the roofing company directly. The facility policy stated that repair requests may be entered into the TELS system to create a work order.
Failure to Attempt GDR for Psychotropic Medication
Penalty
Summary
The facility failed to ensure Resident #9 was free from unnecessary psychotropic medication use when it did not attempt a gradual dose reduction (GDR) for Quetiapine Fumarate and did not document that a GDR was clinically contraindicated. Resident #9 was a male resident with unspecified dementia, lack of coordination, aphasia, dysphagia, and muscle weakness, and his BIMS score was 04, indicating severe cognitive impairment. His quarterly MDS reflected that he was taking an antipsychotic medication on a routine basis, and the care plan addressed psychotropic medication use with a goal to reduce psychoactive medication use through the review date. Physician orders showed Quetiapine Fumarate 200 mg by mouth twice daily for depression, started on 06/01/2024, and the medication administration record showed he continued to receive it in March 2026. Record review showed there had been no GDR for the medication. A consultant pharmacist communication dated 05/19/2025 recommended evaluating the resident for a trial dose reduction and suggested reducing Quetiapine 200 mg BID to 150 mg BID, but the physician response area was blank. In interviews, the MD stated he had started with the facility in June 2025 and would need to review the resident’s records and behaviors to determine whether a GDR would be beneficial; the CDON stated pharmacy recommendations were reviewed by the nurse practitioner or physician, but she was not sure why this resident’s GDR recommendation was not addressed; and the ADM stated the DON/ADON were responsible for monitoring GDRs and pharmacy recommendations.
Incomplete care planning for resident behaviors and dining needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #25 that addressed her verbal behaviors and included measurable objectives and timeframes. Resident #25 was a [AGE]-year-old female with diagnoses including non-Alzheimer's dementia, malnutrition, hyperlipidemia, diabetes mellitus, and anemia. Her quarterly MDS indicated she was rarely or never understood, and the behavior section did not identify verbal, physical, or other behavioral symptoms during the look-back period. Her comprehensive care plan included a focus on communication problems related to hearing deficit and impaired cognition/dementia, along with a psychotropic medication focus, but the documented interventions did not specifically address her yelling out or include interventions tied to those behaviors. During observations, Resident #25 was seen in her room screaming out while lying in bed without other apparent signs of pain or distress, and later was observed in the sitting room grabbing at things that were not visible and occasionally screaming out. Staff interviews confirmed that yelling out was a normal and ongoing behavior for her. An LVN stated the resident had been yelling out since she began working at the facility, that the resident was often placed in the living area to watch television, and that the resident yelled for no particular reason. A CNA stated the resident would pull on things, reach for things that were not there, and yell, and that staff would take her back to her room if she yelled around other residents. Another LVN stated the resident would mumble, staff could not understand her, and yelling had always been her normal behavior, but the root cause was unknown. The MDSC stated she was responsible for comprehensive care planning and believed the verbal outbursts may have become so normalized that they were not documented by direct care staff, which prevented them from being reflected on the MDS and then translated into the care plan. The ADM stated that yelling out was a behavior discussed almost every morning, but it failed to be care planned. The CDON stated she did not know what interventions were determined to help manage or reduce the yelling, and that individualized interventions should have been documented in progress notes and listed in the care plan if they were effective. The facility policy required the interdisciplinary team to develop a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The facility also failed to update Resident #65's care plan to reflect that he no longer required disposable dinnerware. Resident #65 was a 79-year-old male with diagnoses including alcohol use, alcohol polyneuropathy, dementia, and type 2 diabetes. His quarterly MDS showed severe cognitive impairment with a BIMS score of 01, and he required supervision or touching assistance with eating and used a wheelchair. His care plan had documented prior behaviors involving washing dinnerware in the toilet and being provided disposable plates only, but those behaviors were later marked discontinued as no longer applicable. A progress note stated that the resident had no current behaviors of washing dishes in the toilet and no longer needed Styrofoam plates for meals. Despite that, an observation showed him being served lunch on a foam plate in the dining room, and staff interviews indicated they were unaware of why he was still receiving foam plates.
Failure to Provide Needed Fingernail Care
Penalty
Summary
The facility failed to ensure Resident #12, who was unable to complete activities of daily living independently, received needed grooming care when his fingernails were not trimmed or cut. Resident #12 was an [AGE] year-old male admitted on [DATE] with diagnoses including diabetes mellitus, unspecified dementia, myopathy, and unspecified abnormalities of gait and mobility. His MDS reflected a BIMS score of 07, indicating severe cognitive impairment, and he required partial/moderate assistance with personal hygiene. His care plan and bedside Kardex directed staff to physically assist with all ADLs as needed. During observation on 03/03/2026 at 10:44 AM, Resident #12 was noted to have long, jagged fingernails extending past his fingertips with black dirt and debris under them. He stated the nurses refused to cut his fingernails and that he did not like them long. Interviews with CNA A, RN C, the CDON, and the ADM showed confusion about who was responsible for nail care, with staff stating that CNAs should not clip diabetic residents' nails, that nurses were responsible for clipping, and that Resident #12 was not on a scheduled date for trimming. The facility policy stated that residents unable to carry out ADLs should receive necessary services to maintain good nutrition, grooming, and personal oral hygiene from qualified staff.
Unsafe Self-Shaving and Unsecured Razors
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for one resident who kept disposable razors in her possession and used them without supervision. Resident #77 had diagnoses including high blood pressure, renal insufficiency, hyponatremia, glaucoma, muscle weakness, and cognitive communication deficit. Her MDS reflected she needed partial/moderate assistance with oral hygiene, dressing, and personal hygiene, and her BIMS score was 12, indicating moderately impaired cognition. Her care plan identified her as at risk for impaired visual function related to glaucoma and as having an ADL self-care performance deficit related to weakness, unsteady gait, and impaired cognition. During observation, the resident was seen shaving herself with a disposable razor while holding a handheld mirror and using outside light to see, and she was able to shave her chin for about 5 minutes without staff approaching her. In interviews, she stated she had glaucoma, used eye drops, and kept a plastic bag of approximately 5 disposable razors in her purse, which she showed to the surveyor. Staff stated they were not aware she had disposable razors in her possession, that they had not previously seen her shave herself, and that no one was assigned to check her room daily, so daily checks were missed.
Laundry Room Water Leak Not Addressed
Penalty
Summary
The facility failed to maintain dry, water-leak-free conditions in its only laundry room, where a plumbing line on the dirty side behind the washing machine was observed leaking water onto the floor and into the dirty laundry collection room. During the observation, a blue cloth was placed at the back of the main leak area to soak up water, and white blankets were placed at the corners of the washing machine nearest the wall to absorb water from the leak. Laundry Service Staff I stated the leak had been occurring since around the end of December 2025 and that she had notified the FMD at that time. She reported that she had been using dry blankets to soak up the water while the leak continued from the main water line behind the washing machine and sometimes flowed into her work area. The FMD stated Staff I reported the leakage to him two weeks earlier and that he had applied Flex Seal spray, but the leak started again. The FMD described the leak as minor and said it could be dried with a blanket. The ADM stated the unresolved leak could pose a fall hazard to laundry staff. Review of the maintenance logbook and Tels work order report did not address the laundry room water leak.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely, as observed on 01/08/2025. A medication cart was left unlocked in the hallway outside a resident's room, with the keys placed on top, while the medication aide (MA B) was inside a restroom washing hands and obtaining gloves. This action left the medications accessible to unauthorized individuals, including residents, staff, and visitors. Additionally, the facility's only medication storage room was found unlocked and unattended, further compromising the security of medications. Interviews with MA B and the Director of Nursing (DON) revealed that MA B was aware of the policy to never leave a medication cart unlocked and unattended, but was sidetracked while looking for gloves. The DON confirmed that the medication storage room should have been locked and that staff had been instructed to keep medication carts locked and keys on their person. The facility's policy mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel, to prevent unauthorized access and potential drug diversion.
Failure to Discard Expired Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in its only kitchen, as observed during a survey. Specifically, the facility did not ensure that expired pantry items were discarded, which could potentially place residents at risk for health complications and foodborne illnesses. During an inspection of the kitchen pantry, several containers of spices, including Italian Seasoning, Parsley Flakes, Ground Cumin Seeds, Ground Turmeric, and Curry Powder, were found with expired dates written on them. These items were not discarded as required by food safety standards. Interviews with the Dietary Manager (DM) and Assistant Dietary Manager (ADM) revealed that employees were responsible for labeling food items with the received date, date of opening, and expiration date if a use-by date was not printed on the product. The facility claimed to follow guidance from the Texas Food Establishment Rules (TFER). However, a review of the FDA 2022 Food Code indicated that food held beyond its labeled use-by or expiration date must be discarded, and expired food often falls into the category of unsafe food that should be discarded. The facility's failure to discard expired food items was a direct violation of these standards.
Failure to Ensure Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure the dignity and independence of a resident during a dining experience. Specifically, a Speech-Language Pathologist (SLP) stood over a resident while assisting her with eating, which compromised the resident's right to be treated with respect and dignity. The resident, an elderly female with Alzheimer's, difficulty in walking, muscle weakness, cognitive communication deficit, and osteoporosis, was observed during a lunch service where the SLP was conducting an evaluation due to the resident's recent weight loss. The SLP admitted to being unsure about whether she should sit or stand while assisting the resident, indicating a lack of clarity in training. The Director of Rehabilitation (DOR) stated that the expectation was for staff to be seated while assisting residents with feeding, although this was not explicitly covered in evaluations. The facility's feeding checklist for training staff did not include instructions for staff to sit while providing feeding assistance. This oversight in training and practice led to the failure in promoting the resident's dignity and independence during meals.
Failure to Coordinate PASARR Assessments for a Resident
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program for Resident #63, who was reviewed for PASARR services. The social worker (SW) did not assess Resident #63 for a referral for PASARR services based on his behaviors. Additionally, the Minimum Data Set Coordinator (MDSC) did not refer Resident #63 for a Level II PASARR Evaluation by the local Local Intellectual and Developmental Disability Authority (LIDDA). This oversight placed residents at risk for exclusion from PASARR services. Resident #63, a male with severe cognitive impairment, was admitted to the facility with diagnoses of Depression, Unspecified, and Schizophrenia, Unspecified. Despite these diagnoses, the SW was unaware of them and did not refer the resident for a P-2 evaluation. The resident's medical records did not reveal a P-2 or referral to the LIDDA. The MDSC, who was responsible for PASARR eligibility and referrals, failed to retrieve the correct P-1 document from the Simple database, which indicated the presence of a mental illness (MI). This error resulted in the absence of a P-2 submission for the LIDDA. The facility's administrator stated that the SW and MDSC were responsible for PASARR eligibility and referrals. The facility followed PASARR division guidelines, and safeguards such as team meetings and MDSC checks were in place. However, the failure of the SW to assess the resident for MI and the MDSC's failure to retrieve the correct P-1 document from Simple were identified as process failures. The CMS RAI Manual requires a Level II Resident Review Evaluation referral for individuals exhibiting symptoms suggesting a mental illness diagnosis.
Failure to Address High Elopement Risk in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident identified as being at high risk of elopement. The resident, a male with severe cognitive impairment, was assessed with a high elopement risk score of 14. Despite this assessment, the resident's care plan, last revised in October 2024, did not include any interventions for elopement or wandering. This oversight placed the resident at risk of having unmet needs related to their safety and well-being. Interviews with facility staff revealed that the responsibility for creating care plans lay with the MDS Coordinator. However, due to a recent change in personnel, the Director of Nursing acknowledged that the resident's care plan did not address the elopement risk. The MDS resource, who had been in the position since 2019, confirmed that residents with any risk of elopement should have specific interventions included in their care plans. The facility's policy mandates that a comprehensive care plan be developed within seven days of completing the resident's minimum data set, which was not adhered to in this case.
Failure to Maintain Clean Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not placing the resident's oxygen tubing in a bag when not in use. This oversight was observed during a survey, where the oxygen tubing was found laying on top of the concentrator and not dated. The resident, who was cognitively intact, expressed that the nurses generally changed her oxygen tubing weekly, but she preferred it to be clean due to her respiratory condition. The resident had a history of heart failure, acute upper respiratory infection, obstructive sleep apnea, and shortness of breath, and her care plan included interventions for oxygen therapy as ordered by the physician. Interviews with facility staff, including an LVN and the DON, confirmed that the oxygen tubing should be changed weekly and kept in a bag when not in use, as per the physician's order and facility policy. The DON stated that staff were educated on these procedures, and the facility policy required oxygen equipment to be maintained in a clean and sanitary manner. The failure to adhere to these standards could lead to respiratory infections, as noted by the staff, although the report does not specify any direct consequences for the resident involved.
Failure to Monitor and Discontinue Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was adequately monitored and free from unnecessary drugs. Specifically, the facility did not obtain a stop date for an antibiotic, Cipro, prescribed to a resident for a urinary tract infection. The resident, a male with a history of neuromuscular dysfunction of the bladder, hypertension, legal blindness, and a history of brain cancer, was prescribed Cipro starting on January 1, 2025, but the order lacked a specified duration for the antibiotic therapy. The resident's care plan indicated that the Cipro was intended for a short-term treatment of 5 to 7 days, yet the medication administration record showed that the resident received 14 doses without a stop date being clarified. Additionally, another antibiotic, Levofloxacin, was prescribed for a different infection, but the facility did not discontinue the Cipro when the new antibiotic was ordered. Interviews with facility staff, including an LVN, the DON, and a PA, revealed that there was a lack of adherence to the protocol of obtaining stop dates for antibiotics, and the oversight was not caught until later. The facility's policy on unnecessary drugs, which requires that each resident's drug regimen be free from unnecessary drugs, was not followed. The failure to obtain a stop date for the Cipro and the concurrent use of two antibiotics without proper coordination could potentially lead to negative effects, although no immediate adverse effects were noted for the resident during the time of the deficiency.
Inadequate Hand Hygiene During Peri Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA C and NA D during peri care for Resident #75. During an observation, both staff members did not wash their hands or use alcohol-based hand sanitizer when changing gloves while removing a soiled brief and applying a clean brief. This lapse in protocol occurred despite the facility's policy, which requires hand hygiene after removing gloves, and the training provided to staff on infection control measures. Resident #75, a cognitively intact [AGE] year-old female, was admitted with diagnoses including acute respiratory failure and chronic obstructive pulmonary disease. Her care plan highlighted the need for vigilant infection control due to her bowel and bladder incontinence. Interviews with the involved staff and the Director of Nursing (DON) confirmed that the expected procedure was not followed, posing a risk of cross-contamination and potential infection to the resident.
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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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