Ridgecrest Retirement And Healthcare Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Waco, Texas.
- Location
- 1900 W State Hwy 6, Waco, Texas 76712
- CMS Provider Number
- 455670
- Inspections on file
- 31
- Latest survey
- June 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ridgecrest Retirement And Healthcare Community during CMS and state inspections, most recent first.
A resident with multiple psychiatric and cognitive diagnoses was able to hoard 21 pills after the facility failed to communicate and implement provider orders requiring direct supervision during medication administration. The lack of staff awareness and breakdown in processing psychiatric NP notes resulted in the resident accumulating medications with the intent to commit suicide, which was only discovered after the resident disclosed his plan to a social worker. The incident was not self-reported to the state agency, and staff had not been in-serviced on the specific supervision requirements.
Three newly admitted residents did not receive comprehensive MDS assessments within the required 14-day timeframe, with incomplete or missing care plans also noted. Staff interviews revealed confusion over responsibility for assessment completion and delays attributed to staffing issues and reliance on remote workers. Facility policy requires timely MDS completion, but records showed this was not followed, potentially impacting resident care.
The facility did not develop or complete comprehensive care plans for three residents, including one with communication and rehabilitation needs, one with multiple complex diagnoses, and one with a wound requiring specific care. Staff interviews and record reviews confirmed that care plans were missing or incomplete, which hindered staff in providing appropriate and individualized care.
The facility failed to ensure proper pharmaceutical services by not checking blood pressure before administering antihypertensive medication to a resident, not providing a physician-ordered medication to another resident due to unavailability, and storing expired medications in a medication room. Staff interviews revealed gaps in communication and unclear responsibilities for medication monitoring and storage.
Two residents did not have their comprehensive MDS assessments accurately completed, with one missing the admission MDS entirely and the other having only a single section filled out. Staff interviews revealed that assessments were compiled by both onsite and remote staff, but lapses in responsibility and staffing shortages led to incomplete documentation of residents' healthcare status and needs.
A resident admitted with multiple medical conditions did not have a baseline care plan developed within the required 48-hour timeframe. The care plan was completed four days after admission due to the responsible social worker being on vacation, and other staff were unaware of the missed deadline. Facility policy required the baseline care plan to be completed within 48 hours to address immediate needs.
A resident with a history of stroke, hemiplegia, and communication impairment was not evaluated for speech therapy services despite physician orders and a care plan trigger for communication needs. The resident, who was cognitively intact and used a communication board, experienced frustration and emotional distress due to staff not taking time to listen and the lack of therapy intervention. Facility staff interviews revealed that therapy screening was not initiated because nursing did not notify therapy of the resident's needs, and the care plan addressing communication was incomplete.
Two residents experienced medication errors when one did not receive a prescribed dose due to unavailability and another was nearly given a blood pressure medication without the required pre-administration assessment. Staff failed to communicate medication shortages and did not follow protocols for checking vital signs before administering medications, resulting in a medication error rate above 5%.
A resident with a history of stroke, hemiplegia, and expressive aphasia was not provided with timely PT, OT, or ST evaluations and treatment as ordered upon admission. Despite clear triggers in the resident's assessment and care area summary, staff failed to communicate the need for therapy, and required screenings were not completed. The resident experienced ongoing communication difficulties and emotional distress, while facility policies for therapy screening of new admissions were not followed.
A nurse failed to perform hand hygiene between glove changes while providing wound care to a resident with multiple medical conditions, despite facility policy and training requiring handwashing when moving from dirty to clean surfaces. This lapse was observed during a wound care procedure and confirmed through staff interviews and policy review.
A resident with multiple medical conditions and a safe smoking assessment was found to be keeping a lighter and cigarettes in her room, contrary to facility policy requiring smoking materials to be stored at the nurse's station. Staff interviews revealed inconsistent enforcement of the policy, and the resident's care plan had not been initiated at the time of the survey.
A resident with multiple mental health diagnoses disclosed to a social worker an intent to commit suicide and showed that he had hoarded 21 pills for this purpose. Although the social worker notified the ADM and DON and the resident was sent to a psychiatric hospital, the incident was not reported to the state agency as required. The DON confirmed the lack of timely reporting, and the ADM stated he did not believe the event needed to be reported since no harm occurred. Facility policy required incident review and investigation, but lacked specific guidance on reporting requirements.
The facility did not make the survey results binder readily available or easily identifiable to residents or the public, as required by policy. Observations and resident interviews confirmed that individuals were unaware of where to find survey results, and the binder was kept in the administrator's office rather than in a common area.
Three residents with recent falls did not have their care plans reviewed or revised to reflect new interventions, despite having complex medical histories and multiple incidents. Staff interviews revealed that care plan updates were delayed due to workload and communication issues, and record reviews showed that care plans remained blank or outdated, contrary to facility policy.
A resident with quadriplegia and other medical conditions was found to have his call light out of reach, contrary to his care plan and facility policy. Staff interviews confirmed the expectation that call lights should be accessible to allow residents to request assistance. The facility's policy requires call lights to be within arm's reach, but this was not adhered to, potentially affecting the resident's ability to have his needs met.
A CNA failed to draw the privacy curtain while providing peri care to a resident with severe cognitive impairment, compromising the resident's privacy and dignity. The facility's policy mandates protecting resident privacy during personal care, which was not adhered to in this instance.
A facility failed to update a resident's care plan to reflect their current dietary needs, leading to a discrepancy between the physician's order for a regular texture diet and the care plan's documentation of a mechanical soft/ground meat texture. The resident, with conditions including quadriplegia and cognitive communication deficit, confirmed the diet change, but staff interviews revealed the care plan was not updated, risking incorrect dietary provision.
A facility failed to ensure proper storage of a resident's oxygen mask and tubing, which were left exposed and not bagged for sanitation when not in use. This oversight was observed by a CNA and confirmed by the DON, who stated that all staff should comply with the facility's policy for using oxygen equipment. The resident, who had COPD and other health conditions, required continuous oxygen therapy. However, the facility lacked a specific policy for the safe storage of oxygen equipment, contributing to the deficiency.
A facility failed to ensure a resident with pressure ulcers received necessary treatment and services, as required by professional standards. The resident had a verbal order for dressing changes twice daily, but documentation was missing for several days in August. Interviews with the DON, an LVN, and an RN confirmed that wound care was to be documented, yet records were incomplete. Attempts to contact the WCD and WCND were unsuccessful, and the facility's Wound Care policy was not consistently followed.
The facility failed to meet food safety standards, with unlabeled and improperly sealed food items in storage, and dietary staff not practicing proper hand hygiene and equipment sanitization. Observations included exposed food in the refrigerator and freezer, improper glove use, and unsanitized utensils. Interviews with the DM and DON highlighted unmet expectations for food safety, potentially leading to cross-contamination and resident illness.
The facility failed to ensure that call lights were within reach for two residents, both of whom were moderately cognitively impaired and had significant medical conditions. Observations showed that their call lights were on the floor and inaccessible, preventing them from easily calling for assistance. Staff interviews confirmed awareness of the importance of accessible call lights, yet the deficiency persisted, potentially placing residents at risk.
The facility failed to ensure accurate MDS documentation for three residents, leading to discrepancies in their care plans. A resident's MDS did not reflect dialysis services despite receiving them, another was inaccurately documented as receiving dialysis, and a third was incorrectly noted to have an indwelling catheter. These inaccuracies could lead to inappropriate care planning and service delivery.
A resident with moderate cognitive impairment was not allowed to assist with her daily showers, was found soiled and unclothed in bed, and did not have clean linens provided. Despite the facility's policy to allow residents to assist with their ADLs and ensure clean linens, the resident's dignity and quality of life were compromised. Interviews with the DON and a CNA revealed inconsistencies in care practices and communication with the resident's family.
The facility failed to develop accurate care plans for two residents, leading to deficiencies in care. One resident's care plan incorrectly documented an indwelling catheter, while another's care plan omitted a full code advance directive. Interviews with staff confirmed the inaccuracies and the importance of accurate documentation to ensure appropriate care.
Failure to Supervise Medication Administration Leads to Resident Hoarding Pills
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, who had diagnoses including schizophrenia, cognitive communication deficit, depression, unspecified dementia, and anxiety disorder, was known to be at risk for medication non-compliance and suicidal ideation. Documentation in the resident's care plan and psychiatric nurse practitioner (NP) notes indicated the need for staff to supervise the resident during medication administration, remain in the room, and verify that the resident swallowed his medications. Despite these documented requirements, the facility did not communicate or implement the necessary supervision for the resident during medication administration. The psychiatric NP's notes from two separate visits indicated that the resident was pocketing medications and required direct observation to ensure ingestion. However, these notes were not properly reviewed or integrated into the resident's care plan or daily practice due to communication lapses, including issues with the facility's fax system and lack of clear responsibility for processing provider notes. As a result, staff were unaware of the need for enhanced supervision, and the resident was able to accumulate 21 pills in his room. The deficiency was discovered when the resident disclosed to a social worker that he intended to use the hoarded medications to commit suicide. The social worker found the medications in the resident's locked bedside table and reported the incident to facility leadership. The resident was subsequently transferred to a psychiatric hospital. The facility did not self-report the incident to the state agency, and there was no evidence of staff in-service training on the specific requirements for medication administration supervision as outlined in the resident's care plan and provider orders.
Failure to Complete Timely Comprehensive MDS Assessments for New Admissions
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within 14 calendar days after admission for three residents, as required by regulation. For one resident, the comprehensive MDS sections were not completed until several weeks after admission, and the care plan was incomplete, only noting a behavior problem and medication use. Another resident's MDS sections were not signed as completed until well after admission, and no comprehensive care plan had been started for this individual. For the third resident, only one section of the comprehensive MDS was completed and signed, with no evidence of a full assessment. Interviews with facility staff revealed confusion and lack of clarity regarding responsibilities for timely completion of MDS assessments and care plans. The DON stated that care plans are a group effort, with the social worker responsible for opening the baseline care plan, and acknowledged that delays or inaccuracies in MDS completion could impact staff knowledge of resident care needs and preferences. A remote LVN indicated that while he compiles information for the MDS, he is not responsible for ensuring timeliness, placing that responsibility on the VPR. The VPR confirmed awareness of late MDS submissions, attributing the issue to an unfilled MDS position and reliance on remote workers to assemble assessments from onsite staff documentation. Review of facility policy confirmed the requirement to complete and transmit all MDS assessments in accordance with OBRA regulations. The failure to complete timely and accurate comprehensive assessments and care plans for newly admitted residents was directly observed in the records reviewed and acknowledged by staff, with the potential to affect the quality and appropriateness of care provided.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by policy and regulation. For one resident with a history of stroke, hemiplegia, and communication difficulties, the care plan was incomplete and only addressed behavioral issues and medication, despite the resident expressing ongoing challenges with communication and a desire for speech and rehabilitation services. Observations and interviews revealed that staff did not consistently take the time to communicate with the resident, and there was no evidence of therapy referrals or interventions to address her communication needs. Another resident, with multiple diagnoses including cancer, kidney failure, and depression, did not have a comprehensive care plan initiated at all. The Director of Nursing confirmed that the care plan had not been started, citing staffing issues and turnover in the MDS RN position as contributing factors. This lack of a care plan left staff without clear guidance on how to address the resident's needs and preferences. A third resident, who had a wound on the right foot, was not care planned for this condition, despite having physician orders for wound care. The existing care plan only addressed a separate wound on the abdomen and did not include interventions or goals for the foot wound. Staff interviews indicated that incomplete or missing care plans hindered their ability to provide appropriate care and understand residents' backgrounds and needs.
Failure to Ensure Accurate Medication Administration and Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents and in one medication room, as evidenced by multiple deficiencies in medication administration and storage. For one male resident with diagnoses including dementia, epilepsy, and osteoporosis, the medication aide (MA) did not check the resident's blood pressure prior to administering Metoprolol, a medication with specific parameters requiring blood pressure and heart rate checks before administration. The MA stated there was no area to document blood pressure in the medication administration record and therefore assumed it was not necessary to check, despite the physician's order specifying parameters. Review of the medication administration record showed no documented blood pressure checks prior to administration for several days. Another deficiency involved a female resident with a history of diverticulitis, mood disorder, anxiety, and hypertension. The facility failed to ensure the availability of her physician-ordered Hydralazine, resulting in a missed dose. The MA was unaware of the reason for the medication's unavailability and stated that medications were typically reordered when a 4-5 day supply remained. The MA reported notifying the charge nurse, but the charge nurse stated she had not been informed and would have checked the emergency kit or contacted the pharmacy if notified. Documentation confirmed the medication was not available at the time of administration. Additionally, during an observation of a medication room, expired medications were found, including bottles of melatonin, folic acid, and acetaminophen suppositories. The LVN interviewed was unsure of the process for checking expiration dates in the medication supply room and stated that medication aides were responsible for keeping the room clean and stocked. The DON confirmed there was no designated person responsible for checking expiration dates and that medication aides and nurses should have checked the medication rooms daily for expired drugs. Facility policy required accurate and timely provision of medications, proper storage, and adherence to physician orders, which was not followed in these instances.
Failure to Complete and Accurately Reflect Resident Status in MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments accurately reflected the healthcare status and needs of two residents. For one resident, the admission MDS assessment was not completed, despite the resident having multiple diagnoses including encephalopathy, congestive heart failure, hypothyroidism, and muscle weakness. Documentation showed that the resident had a care plan addressing wound care and infection risk, and physician orders for wound treatment were present, but the required MDS assessment was missing. For the second resident, only Section F (Preferences for Customary Routine and Activities) of the comprehensive MDS assessment was completed and signed, with the remainder of the assessment left incomplete. Interviews with staff revealed that the process for completing MDS assessments involved both onsite and remote staff. The LVN responsible for entering assessment data stated that most assessments were conducted by facility staff and then compiled by remote workers, but he was not responsible for ensuring timely completion. The VPR, who was responsible for submitting MDS assessments, acknowledged delays due to an unfilled MDS position and confirmed that incomplete or late assessments could result in not identifying residents' care needs. The facility's policy required all MDS assessments to be completed and transmitted in accordance with OBRA regulations, but this was not followed for the two residents in question.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by policy. The resident, a male admitted with multiple diagnoses including a displaced hip fracture, muscle weakness, cognitive communication deficit, hypertension, and emphysema, was found to have a baseline care plan initiated four days after admission, rather than within the mandated 48-hour window. The resident's admission MDS indicated he was cognitively intact at the time of admission. Interviews with facility staff revealed that the social worker was primarily responsible for opening and completing baseline care plans, with input from the DON and nurses. The social worker acknowledged being aware of the 48-hour requirement but stated she was on vacation during the period in question and completed the care plan upon her return. The administrator confirmed that the responsibility was shared but primarily assigned to the social worker due to the absence of an MDS nurse. Both the DON and administrator were unaware that the baseline care plan had not been completed within the required timeframe. Facility policy clearly stated that a baseline care plan must be developed within 48 hours to meet immediate resident needs.
Failure to Provide Timely Therapy Evaluation for Communication Deficit
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to maintain or improve her ability to carry out activities of daily living (ADLs), specifically regarding her communication abilities. The resident, a cognitively intact female with a history of stroke, hemiplegia, high blood pressure, diabetes, and non-Alzheimer's dementia, was admitted with a communication deficit. Her comprehensive MDS assessment and Care Area Assessment (CAA) indicated impaired expressive communication and triggered care planning for communication and ADL functional/rehabilitation potential. However, her care plan was incomplete and did not address her communication needs. Despite physician orders allowing for PT, OT, and ST evaluation and treatment as indicated, the resident was not evaluated by speech therapy (ST) upon admission or during her stay until after surveyor intervention. The SLP and DOR both stated that their process relied on nursing staff to notify therapy of a decline or need for therapy, and no such referral was made. Nursing staff were unaware of the need to communicate the presence of a communication board or the resident's ongoing communication difficulties to therapy. The resident herself reported frustration and emotional distress due to staff not taking the time to listen to her, and she expressed a desire for speech therapy services, which had not been offered. Interviews with facility staff revealed a lack of communication and coordination between nursing and therapy departments regarding the resident's needs. The SLP confirmed that she had not been informed about the communication board and had not screened the resident until prompted by the survey. The DOR and ADM acknowledged that the process for therapy screening was not followed for this resident, and that therapy services could have been authorized by the facility if payor source issues were present. The resident's family member also indicated that the resident could benefit from speech therapy and that her Medicaid status was in transition, which may have contributed to the lack of therapy services.
Medication Error Rate Exceeds 5% Due to Missed Dose and Lack of Pre-Administration Assessment
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a calculated rate of 6.45% based on 2 errors out of 31 observed opportunities. The first error involved a female resident with a history of diverticulitis, mood disorder, anxiety, and hypertension, who did not receive her physician-ordered hydralazine as it was not available during the scheduled medication pass. The medication aide was unaware of the unavailability until the time of administration and did not notify the charge nurse, resulting in the resident missing a dose for her anxiety and blood pressure management. The second error involved a male resident with dementia, epilepsy, polyneuropathy, and osteoporosis, who was prescribed Metoprolol Tartrate with specific parameters to hold the medication if his blood pressure or heart rate fell below certain thresholds. The medication aide prepared and was about to administer the medication without checking the resident's blood pressure, as there was no designated area in the medication administration record for documenting this assessment. The aide assumed the check was unnecessary and only measured the blood pressure after being prompted by the surveyor. Interviews with staff revealed a lack of communication and understanding regarding medication availability and the need for pre-administration assessments. The charge nurse was not informed about the missing hydralazine, and the admitting nurse did not enter blood pressure parameters into the electronic system for the second resident. Facility policies required timely medication availability and pre-administration assessments, but these were not followed, leading to the observed deficiencies.
Failure to Provide Timely Specialized Rehabilitative Services
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, hemiplegia, and expressive aphasia was not provided with specialized rehabilitative services, including physical therapy (PT), occupational therapy (OT), and speech therapy (ST), as ordered upon admission. The resident's admission records included standing orders for PT, OT, and ST to evaluate and treat as indicated, and her comprehensive MDS assessment and Care Area Assessment (CAA) identified communication and ADL functional/rehabilitation potential as areas of concern. Despite these triggers, the care plan was incomplete and did not address her rehabilitative needs, and no therapy evaluations or screenings were conducted in a timely manner. Interviews with facility staff revealed that the process for initiating therapy services relied on nursing staff to notify therapy of a decline or need, rather than automatically screening all new admissions as required by facility policy. The speech-language pathologist (SLP) and director of rehabilitation (DOR) both stated that they had not been informed by nursing about the resident's communication board or potential need for therapy. The SLP only became aware of the need for a screening after being interviewed by surveyors, and subsequently determined that the resident could benefit from a higher-tech communication device and PT for a right leg contracture. Nursing staff were unclear about the resident's needs and the process for referring residents for therapy, leading to further delays. The resident herself reported difficulty communicating with staff, emotional distress when staff did not take the time to listen, and a desire for help with her speech and right leg. Her family member confirmed her ongoing communication difficulties and recent decline in mobility following a fall. Facility policies required therapy screenings for all new admissions and for residents identified by the interdisciplinary team as needing rehabilitation, but these policies were not followed, resulting in the resident not receiving timely and appropriate rehabilitative services.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper infection prevention and control procedures during wound care for a resident. The nurse, after removing soiled dressings and cleansing a wound on the resident's right foot, changed gloves without washing or sanitizing her hands before applying a clean dressing. This action was observed during a wound care procedure and was not in accordance with the facility's hand hygiene policy, which requires hand hygiene after removing gloves and before moving from a contaminated to a clean body site. The resident involved was an elderly female with multiple diagnoses, including encephalopathy, congestive heart failure, hypothyroidism, and muscle weakness. Her care plan noted a risk of infection due to her tendency to pick at wounds, and she had a physician's order for daily wound care on her right foot. The nurse's failure to perform hand hygiene between glove changes during the wound care process was observed directly by surveyors. Interviews with the nurse, DON, and administrator confirmed that staff had been trained on infection control and handwashing procedures, and that the expectation was for hand hygiene to be performed when moving from dirty to clean surfaces, even when gloves are changed. The facility's policies on hand hygiene and infection prevention were reviewed and found to require these practices, which were not followed during the observed incident.
Failure to Enforce Smoking Material Storage Policy
Penalty
Summary
The facility failed to follow its established smoking policy for one resident who was identified as a smoker. According to the facility's policy, residents' smoking materials, including lighters and cigarettes, are to be kept at the nurse's station and not in residents' rooms. However, during an observation and interview, the resident was found to have both a lighter and a pack of cigarettes stored in her bedside drawer. The resident confirmed that she kept these items in her room and was able to light her own cigarettes, although staff accompanied her during designated smoke breaks. Staff interviews revealed inconsistent practices regarding the storage of smoking materials, with one LVN stating that smoking materials should be kept at the nurse's station but admitting uncertainty about the location of the resident's lighter. The DON also confirmed that smoking materials should not be kept in residents' rooms. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had multiple medical diagnoses including cancer, high blood pressure, kidney failure, malnutrition, depression, white matter disease, and vitamin D deficiency. The resident's care plan had not been started at the time of review, and although a safe smoking assessment indicated she could smoke without supervision, the facility did not ensure compliance with its policy regarding the storage of smoking materials. This lapse was identified through observations, interviews, and record reviews conducted by surveyors.
Failure to Timely Report Resident Suicidal Ideation and Medication Hoarding
Penalty
Summary
The facility failed to ensure that an incident involving a resident's suicidal ideation and medication hoarding was reported to the State Survey Agency as required. A resident with diagnoses including schizophrenia, depression, anxiety disorder, and dementia informed the social worker that he intended to commit suicide and had hoarded 21 pills in his locked bedside table for this purpose. The social worker immediately notified the administrator (ADM) and director of nursing (DON), and the resident was subsequently sent to a psychiatric hospital for evaluation and stabilization. Despite the seriousness of the incident, a review of facility records and interviews revealed that the event was not reported to the state agency as required by regulation. The DON confirmed that an internal incident report was only being completed several days after the event and acknowledged that the incident was not reported to the state. The ADM stated that he did not believe the incident needed to be reported since the resident had not consumed the medication and there was no harm at the time, despite recognizing the potential for harm if the plan had been carried out. The facility's policy required all accidents or incidents, including those involving allegations of abuse or neglect, to be reviewed, investigated, and reported to the administrator immediately. However, there was no specific policy outlining the reporting requirements for different types of incidents. The lack of timely reporting of this incident involving suicidal ideation and medication hoarding constituted a deficiency in the facility's compliance with state reporting requirements.
Survey Results Binder Not Accessible to Residents or Public
Penalty
Summary
The facility failed to ensure that residents were aware of where to locate the State Agency (SA) survey inspection results, including surveys, certifications, and complaint/incident investigations. On the date of the survey, observations of the front door area, receptionist desk, and administrative offices revealed there was no survey results binder or notice indicating where such a binder could be found. Interviews with eleven residents confirmed that they did not know where or how to access survey results and had never seen a binder labeled with that information in common areas. Multiple residents expressed interest in knowing the results of previous surveys and investigations. Further investigation revealed that the administrator (ADM) kept the survey binder in his office and only brought it out for state surveyors. The ADM acknowledged that this practice prevented residents and the public from seeing the results of the facility's surveys and investigations. Review of facility policy indicated that the survey binder should be maintained in an area frequented by most residents, such as the main lobby or resident activity room, but this was not being followed at the time of the survey.
Failure to Update Comprehensive Care Plans After Resident Falls
Penalty
Summary
The facility failed to review and revise the person-centered, comprehensive care plans for three residents who experienced multiple falls within a 30-day period. For one resident, the care plan was found to be completely blank with no problems or interventions listed, despite recent falls and a medical history including pneumonia, metabolic encephalopathy, hypertension, chronic pain, heart disease, anxiety disorder, muscle weakness, unsteadiness, lack of coordination, and COPD. Another resident's care plan had not been updated since the previous year, even though the resident had a history of Huntington's disease, unsteadiness, muscle weakness, difficulty walking, and multiple recent falls. The third resident, with diagnoses including hypertension, heart disease, anxiety disorder, Alzheimer's disease, muscle weakness, chronic pain, arthritis, and COPD, also had a care plan that had not been updated since the previous year despite experiencing several falls. Interviews with facility staff revealed that the responsibility for updating care plans was shared between nursing and the MDS coordinator. The MDS coordinator acknowledged that care plans were not updated in a timely manner due to workload and staffing limitations, and that this issue had been communicated to the DON without resolution. The ADON and administrator both confirmed that the expectation was for care plans to be updated after falls were discussed in morning meetings, but this was not occurring as required. Record reviews confirmed that the facility's policy required the interdisciplinary team to develop and implement comprehensive, person-centered care plans that are revised as residents' conditions change. Despite this policy, the care plans for the three residents were not updated to reflect recent falls or new interventions, resulting in incomplete or outdated documentation of care needs and interventions.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents with specific needs. The resident in question, a male with quadriplegia, lack of coordination, hypertension, cognitive communication deficit, and polyneuropathy, was observed to have his call light on the floor behind his bed, out of reach. This observation was made on 12/13/24, and the resident confirmed that his call light is never within reach, requiring him to yell for assistance. The resident's care plan specifically included an intervention to keep the call light within reach due to his dependency on assistance for various activities of daily living. Interviews with facility staff, including a CNA, the DON, and the ADM, revealed that it is the responsibility of all staff to ensure call lights are within reach to allow residents to alert staff when they need assistance. The facility's policy on Routine Resident Checks & Call Lights, revised in July 2013, mandates that call lights should be within arm's reach while the resident is present. The failure to adhere to this policy could result in unmet needs for residents requiring assistance with activities of daily living.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident during personal care. A CNA, who had been working at the facility for five days, provided peri care to a resident without drawing the privacy curtain, making the care visible to anyone entering the room or passing by in the hallway. The resident, a female with severe cognitive impairment and multiple health issues, required extensive assistance with personal hygiene. During the observation, the resident's family member was present, and the room was shared with another resident who was not present at the time. The CNA acknowledged the oversight and admitted that the privacy curtain should have been closed. The Director of Nursing confirmed that maintaining resident privacy during care is mandatory and that the facility's policy requires staff to protect resident privacy by closing doors and drawing curtains during personal care. The facility's policy emphasizes the importance of promoting and protecting resident privacy, dignity, and respect during care.
Inaccurate Care Plan for Resident's Dietary Needs
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected their current dietary needs. The resident, who was admitted with conditions including quadriplegia, hypertension, and cognitive communication deficit, had a physician's order for a regular texture diet with thin liquids. However, the care plan inaccurately documented a mechanical soft/ground meat texture with thin liquids. This discrepancy was identified during a review of the resident's records and confirmed through interviews with the resident, who stated that his diet had been changed during the summer months. Interviews with facility staff, including the MDS coordinator and the Director of Nursing (DON), revealed that the care plan was not updated to reflect the resident's current dietary needs. The MDS coordinator acknowledged the potential negative outcome of the resident receiving the wrong diet texture due to the outdated care plan. The DON and the Administrator (ADM) both emphasized the importance of having accurate and up-to-date care plans to ensure residents receive appropriate care. The facility's policy requires that care plans be comprehensive, person-centered, and revised as the resident's condition changes, but this was not adhered to in this case.
Failure to Properly Store Oxygen Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy. During an observation, it was noted that the resident's oxygen mask and tubing were not stored in a protective bag when not in use, as required for sanitation purposes. This oversight was confirmed by a CNA who acknowledged the necessity of storing the oxygen mask in a protective bag to prevent respiratory infections. The resident in question was an elderly female with a history of COPD, hypertension, type 2 diabetes, atrial fibrillation, major depressive disorder, and seasonal allergies. Her care plan indicated the use of oxygen via nasal prongs at 4.5L continuously, with the possibility of increasing to 10L/m as needed for comfort. The Director of Nursing (DON) confirmed that all staff were expected to comply with the facility's policy regarding the use of oxygen cannulas and nebulizers, which included cleaning and safely storing oxygen masks in protective bags. However, a review of the facility's policies revealed no specific guideline for the safe storage of oxygen cannulas and facemasks in protective bags when not in use. The facility's infection prevention and control program was designed to provide a safe environment and prevent the transmission of infections, but the lack of a specific policy on oxygen equipment storage contributed to the deficiency.
Failure to Document and Complete Wound Care Treatments
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice. The resident, who had moderate cognitive impairment and was at high risk for pressure ulcers, had a verbal order for dressing changes to the coccyx area twice daily. However, there were multiple instances in August 2024 where the required wound care treatments were not documented as completed. Specifically, there were no documented entries for several days, indicating a lack of adherence to the prescribed wound care regimen. Interviews with the Director of Nursing (DON), an LVN, and an RN revealed that wound care was supposed to be documented in the residents' electronic health records and Treatment Administration Records. Despite this, the documentation was incomplete, and attempts to contact the Wound Care Doctor (WCD) and Wound Care Nurse Director (WCND) for further clarification were unsuccessful. The facility's Wound Care policy required staff to apply treatments as per medical orders and record the date, time, and signature of the person providing care, which was not consistently followed in this case.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The reach-in refrigerator and freezer contained food items that were not properly labeled or sealed, exposing them to air. Specifically, sliced deli ham, cheddar cheese slices, and grape jelly were found in unsealed containers, while frozen chicken patties, sweet potato fries, regular fries, and hash browns were in torn bags without labels indicating the received or opened dates. Additionally, a container of banana pudding was improperly sealed, and an expired bottle of browning and seasoning sauce was found in dry storage. Dietary staff did not practice proper hand hygiene and glove use, as observed during food preparation. A staff member was seen handling soiled dishes and then preparing food without changing gloves or washing hands. The same staff member reused a soiled spatula and blender without proper sanitization, and touched the trash can before returning to food preparation without changing gloves or washing hands. The thermometer probe used to check food temperatures was not sanitized between uses, and there were no alcohol wipes available for this purpose. Interviews with the Dietary Manager (DM) and Director of Nursing (DON) revealed that the facility's expectations for food safety and sanitation were not met. The DM and DON both emphasized the importance of labeling, sealing, and sanitizing food items and equipment to prevent contamination and cross-contamination. The DM stated that dietary staff should check for expired items weekly, while the DON expected daily checks. Both acknowledged that the observed practices could lead to cross-contamination and potential illness among residents.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents, Resident #26 and Resident #49, were within reach, which is a violation of resident rights. Resident #26, a male with multiple diagnoses including type 2 diabetes, dysphagia, acute kidney failure, and hemiplegia, was observed with his call light on the floor and out of reach. Despite being moderately cognitively impaired, he expressed that he could not always reach his call light and had to resort to yelling for help. Observations confirmed that the call light was consistently out of reach, which could prevent him from calling for assistance when needed. Similarly, Resident #49, who has diagnoses including paranoid schizophrenia, Parkinson's disease, and atherosclerotic heart disease, was also found with his call light on the floor and out of reach. This resident, also moderately cognitively impaired, indicated that he would have to yell or look for someone if he needed help. Observations confirmed that his call light was not accessible, which could hinder his ability to request assistance promptly. Interviews with staff, including a CNA, RN, and the DON, revealed that they were aware of the importance of keeping call lights within reach and had been in-serviced on this matter. However, despite this training, the call lights for both residents were not accessible, potentially placing them at risk of harm. The facility's policy on call lights was requested but not provided, indicating a possible gap in documentation or adherence to procedures.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. Resident #17's MDS assessments did not reflect that he was receiving dialysis services, despite his care plan indicating a need for dialysis due to end-stage renal disease. Interviews with Resident #17 confirmed that he was indeed receiving dialysis services, highlighting the inaccuracy in his MDS documentation. Resident #28's MDS assessments inaccurately documented that she was receiving dialysis services, although her care plan and interviews with both the resident and a hospice provider confirmed that she was not receiving such services. This inconsistency between the MDS and the resident's actual care needs could lead to inappropriate care planning and service delivery. Resident #44's MDS inaccurately documented the presence of an indwelling catheter, which was not supported by his care plan or physical observation. Interviews with the resident and facility staff confirmed that he did not have a catheter, indicating a failure in accurately updating the MDS. The MDS Coordinator acknowledged the responsibility for ensuring accurate MDS documentation, and the Director of Nursing was unaware of these inaccuracies, which could potentially impact the quality of care provided to the residents.
Failure to Maintain Resident Dignity and Quality of Life
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident by not allowing her to assist with her daily showers, not providing undergarments after changing, and not placing clean linens on her bed. The resident, who has moderate cognitive impairment and requires limited assistance with bathing, expressed that she was not allowed to bathe herself and was made to take showers against her will. Her family member reported finding her soiled and unclothed in bed without a protective pad, indicating a lack of proper care and attention to her needs. Interviews with the Director of Nursing (DON) and a Certified Nursing Assistant (CNA) revealed discrepancies in the facility's practices. The DON stated that residents should be allowed to do as much as they can and that refusals to shower should be documented and reported. However, the resident's family member's concerns were not formally addressed, and the DON denied receiving any communication about the issue. The CNA confirmed that residents have the right to assist with their activities of daily living (ADLs) and that there should always be clean linens available. Despite these statements, the resident was found in unsanitary conditions, highlighting a failure in maintaining her dignity and quality of life.
Inaccurate Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which led to deficiencies in their care. Resident #44's care plan inaccurately documented the presence of an indwelling catheter, despite the resident not having one. This discrepancy was confirmed through a record review and an interview with the resident, who stated he had not had a catheter for a long time. The care plan was not updated to reflect the current status, and there was no physician's order for a catheter, indicating a lack of accurate documentation and assessment. Resident #163's care plan did not address the resident's full code advance directive, which was an active order in the physician's records. The omission of this critical information from the care plan could lead to confusion regarding the resident's wishes in emergency situations. The MDS Coordinator acknowledged the oversight and confirmed that the advance directive should have been included in the care plan to ensure appropriate care and services. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the responsibility for accurate care plan completion lies with the MDS Coordinator. Both acknowledged the importance of reflecting accurate medical information and advance directives in care plans to prevent inappropriate care. The facility's policy on comprehensive person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs, which was not adhered to in these cases.
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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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