San Pedro Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 515 W Ashby Pl, San Antonio, Texas 78212
- CMS Provider Number
- 455689
- Inspections on file
- 47
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at San Pedro Manor during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple chronic conditions sustained a skin tear to the lower shin that was documented by an LVN, who attempted but failed to reach the resident’s POA and did not leave a voicemail, assuming the treatment nurse would notify the family. The treatment nurse documented the wound, obtained MD orders, and provided treatment but did not contact the family, citing a facility practice that charge nurses handle family notification. The resident’s representative reported learning of the injury only upon visiting and seeing the wound, and leadership acknowledged that both the physician and the representative were not notified as required by the facility’s significant change in condition policy.
Surveyors found that a resident did not receive appropriate care for continence or incontinence, including improper catheter care and insufficient measures to prevent UTIs. These lapses resulted in a deficiency related to the standard of care for residents with bowel or bladder needs.
Several residents with intact cognition and ADL deficits reported that their meals, often served in their rooms, were frequently cold. Direct interviews, family input, and resident council records confirmed ongoing issues with food temperature. Observations and temperature checks showed that food items were served well below required temperatures, and staff practices during tray delivery contributed to the problem.
Surveyors observed that kitchen and dish room ceiling vents were dirty, stained, and in some cases rusty, with one vent not fully attached to the ceiling. Both the Food Service Director and Maintenance Director acknowledged the unclean conditions, which did not meet professional standards for food service safety.
A CNA did not follow infection control protocols while providing incontinent care to a resident with multiple health conditions, including failing to sanitize hands before donning gloves, not sanitizing between glove changes, and handling clean briefs after touching soiled items without proper hand hygiene. The DON confirmed these actions were not in line with facility policy, which requires hand hygiene and appropriate PPE use.
CNAs did not fully close a broken privacy curtain while providing incontinent care to a resident who was cognitively impaired and dependent for ADLs, resulting in a lack of privacy during care. Both staff confirmed the curtain was not completely closed and were unaware of how long it had been broken, despite facility policy requiring privacy during care.
The facility did not distribute mail to residents on Saturdays, instead holding weekend mail until Monday, despite policy requiring same-day delivery. Staff interviews and resident council feedback confirmed this practice, resulting in delayed access to mail and a failure to uphold residents' rights to timely and private communication.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility did not maintain a clean and sanitary environment in a shared shower room, as observed by clogged drains with hair, dirty floors, and brown substances present. Staff interviews revealed inconsistent cleaning practices, lack of disinfectant supplies, and unclear division of cleaning responsibilities between CNAs and housekeeping. Policy documents lacked specific guidance for CNAs on cleaning and disinfecting the shower area.
A resident with multiple health conditions, including osteoporosis, was injured during a transfer to a transportation van for dialysis. The transportation driver pushed the resident too quickly, causing the resident's foot to get caught in the ramp gap, resulting in a sprained ankle. The facility failed to ensure a safe environment and adequate supervision, as outlined in the resident's care plan and facility policy.
The facility failed to maintain kitchen sanitation standards, as air vents over the food preparation area were found with dust and fuzz, risking food contamination. Interviews revealed confusion over cleaning responsibilities between kitchen and maintenance staff, contrary to the facility's sanitation policy and Federal Food Code requirements.
A facility failed to report three incidents to the State Survey Agency, violating its policies. One resident sprained an ankle during transport, another had ant bites from ants in her bed, and a third was given incorrect medications. Despite these events, the facility did not report them, citing a lack of perceived severity.
The facility failed to maintain an effective infection prevention and control program, as staff did not wear appropriate PPE while caring for two residents on Enhanced Barrier Precautions. Despite recent training and clear signage, staff only wore gloves instead of both gown and gloves, as required by facility policy. This oversight was acknowledged by the Infection Preventionist and DON, who noted the risk of spreading infections.
The facility failed to report incidents involving a resident's sprained ankle during transport, ant bites on another resident, and a medication error affecting a third resident to the State Survey Agency. These incidents were not reported despite the potential for harm and the facility's responsibility to do so.
A resident's bed was not maintained in proper working condition, potentially risking skin tears, injury, and discomfort. Despite the resident's need to elevate her legs due to edema, the bed's end was not functioning. The resident reported the issue, but staff and maintenance failed to resolve it. Interviews revealed a lack of communication and follow-up, and no work orders were found for the bed, contrary to the facility's policy requiring maintenance issues to be resolved within 72 hours.
The facility failed to maintain an effective pest control program, resulting in a resident experiencing ant bites and a kitchen infested with gnats. The resident, with moderate cognitive impairment, reported ants in her bed, leading to bites on her arms and legs. The kitchen had multiple gnats in food prep areas, despite regular pest control treatments. Staff interviews confirmed ongoing pest issues, posing a risk of food contamination.
A resident with schizoaffective disorder, schizophrenia, and depression was admitted without the proper PASRR Level II evaluation due to an oversight by the Social Worker, who failed to review the resident's clinical records. The PASRR Level 1 screening inaccurately indicated no mental illness, contrary to the resident's documented diagnoses.
A resident with severe cognitive impairment and a history of dysphagia did not receive proper g-tube care as per physician orders, leading to potential infection risks. The nurse responsible admitted to not providing the care, despite documenting it as completed, due to the resident's ability to eat orally. Facility leadership was unaware of the oversight, despite having a system for weekly checks.
A resident with severe cognitive impairment and multiple diagnoses was mistakenly given another resident's medications due to a distraction during medication preparation by an LVN. The resident was supposed to receive Pantoprazole and Tramadol but was given Alprazolam and Hydrocodone-Acetaminophen instead. The error was promptly reported, and the resident was monitored without adverse effects.
A resident's room in the facility was not maintained at a comfortable temperature, with readings reaching 82 degrees Fahrenheit. Despite the resident's complaints to the Maintenance Assistant, the issue persisted, and the Maintenance Director was only informed on the day of the survey. The resident, who has hypertension, anxiety disorder, and COPD, experienced discomfort due to the high room temperature.
A resident with severe cognitive impairment and a g-tube for nutrition did not receive proper g-tube care as per physician orders. The LVN responsible failed to provide the care and falsely documented it as completed. The ADON and DON were unaware of this issue until it was discovered during an observation. This failure to document accurately is considered falsification of records.
A resident with severe cognitive impairment and identified as an elopement risk managed to leave the facility undetected. The resident exited the building after walking past the nurses' station and taking the elevator to the first floor. Although the alarm system was functional, it was not heard by staff, allowing the resident to leave. The resident was found unharmed at a nearby gas station by the police. The incident highlighted inadequate supervision and alarm failure, placing residents at risk.
A CNA in an LTC facility failed to follow proper infection control procedures while providing incontinent care to a resident. The CNA did not change gloves or wash hands after touching a privacy curtain and between glove changes, despite having received infection control training. The DON confirmed these lapses, highlighting a deficiency in maintaining a safe and sanitary environment.
A resident did not receive scheduled doses of Alprazolam due to a delay in delivery from the hospice provider and lack of proper follow-up by facility staff. The resident, who had a history of anxiety and other conditions, missed several doses, which was against the physician's orders and facility policy.
Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and representative of a significant change in condition following a skin tear. The resident was an older male with anxiety disorder, hypertension, and benign prostatic hyperplasia, admitted with a care plan that included treatment for a skin tear to the left lateral shin. An admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Facility incident and accident reports identified a skin tear event for this resident, and physician telephone orders were obtained to cleanse the affected area and apply dressings daily. A progress note documented that an LVN observed a skin tear/abrasion to the left lower shin and attempted to call the resident’s daughter/POA, but there was no answer and no voicemail left. The treatment nurse’s subsequent progress note documented that she was notified of the skin tear and that the wound measured 8x6 cm, and she obtained and implemented MD orders, but did not contact the family, stating that per facility culture the charge nurse was responsible for family notification. The resident’s representative reported she was never contacted by nursing staff and only learned of the skin tear when she visited and saw the injury. Interviews with LVN A confirmed she attempted to call but did not leave a voicemail and believed the treatment nurse would call the family, while the treatment nurse confirmed she did not contact the family. The DON acknowledged that the resident’s representative should have been notified per the facility’s significant change in condition policy, which states that the resident representative will be notified of a change in condition. The Administrator stated that the physician should have been notified but was not, while staff prioritized providing care to the resident at that time.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents with these needs.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for three residents. Multiple residents with intact cognition and deficits in activities of daily living reported that their meals, often served in their rooms, were frequently cold. Direct interviews with these residents confirmed that both breakfast and lunch meals were served at temperatures below recommended standards, leading to dissatisfaction and refusal to eat. Family members also corroborated that meals were often cold when served. Observations and temperature checks revealed that food items such as eggs and sausage were served significantly below the required temperatures, with eggs at 94.82°F (required: 135°F) and sausage at 90.32°F (required: 140°F). Staff interviews indicated that food trays were transported in open tray rack carts after the plastic cover was removed, which contributed to the temperature drop. Resident council meeting records further documented multiple complaints about cold food. Facility dietary policy referenced the Texas Food Establishment Rules, which require adherence to established temperature guidelines, but these were not followed.
Failure to Maintain Clean and Safe Kitchen Ventilation Surfaces
Penalty
Summary
The facility failed to maintain cleanliness and proper condition of overhead ceiling vents in the main kitchen and dish room areas, as observed during a survey. Specifically, seven ceiling vents in the main kitchen were found to have visible dirt, dust particles, and stains, with one vent over the standing floor freezer not fully attached to the ceiling. Additionally, a vent cover over the dish machine in the dish room had several spots of rust accumulation on both the inside and outside surfaces. These conditions were directly observed during a walkthrough of the kitchen with the Food Service Director. Interviews with the Food Service Director and Maintenance Director confirmed awareness of the issues, with both acknowledging the presence of dirty and rusty vents and the need for cleanliness in the food service environment. Review of facility policy and relevant food safety codes indicated that non-food contact surfaces, such as ceiling vents, are required to be kept clean and free of dust, dirt, and debris. The failure to maintain these standards was documented through direct observation and staff interviews.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection control procedures while providing incontinent care to a resident with multiple medical conditions, including Wernicke's encephalopathy, dysphagia, hypothyroidism, hyperlipidemia, hypertension, and asthma. The resident was moderately cognitively impaired, always incontinent of bladder and bowel, and required total assistance with activities of daily living. During the observed care, the CNA washed her hands but then touched the room door with bare hands, did not sanitize her hands before donning gloves, and began care. Throughout the process, the CNA changed gloves multiple times without sanitizing her hands between glove changes. After cleaning the resident's buttocks and removing soiled briefs, the CNA failed to change gloves or sanitize hands before handling clean briefs. Interviews with the CNA and the Director of Nursing (DON) confirmed that the CNA did not follow established infection control protocols, including hand hygiene before gloving and between glove changes, as well as when transitioning from soiled to clean tasks. The DON acknowledged that the room door is considered a contaminated surface and that staff are required to sanitize hands before putting on gloves and between glove changes. Facility policy reviewed indicated that standard precautions, including proper hand hygiene and use of personal protective equipment (PPE), are required for all resident care activities.
Failure to Ensure Resident Privacy During Incontinent Care Due to Broken Curtain
Penalty
Summary
Certified Nursing Assistants (CNAs) E and F failed to ensure complete privacy for a resident while providing incontinent care. During the care, the privacy curtain in the resident's room was not fully closed, leaving the resident potentially exposed to anyone entering the room. The curtain was found to be broken and could only be closed halfway, which was confirmed by both CNAs during an interview. Both staff members acknowledged that the curtain should have been fully closed to protect the resident's privacy, but they were unaware of how long the curtain had been in disrepair. The resident involved had multiple medical diagnoses, including Wernicke's encephalopathy, dysphagia, hypothyroidism, hyperlipidemia, hypertension, and asthma. She was moderately cognitively impaired, always incontinent of bladder and bowel, and required total assistance with activities of daily living (ADLs). The resident's care plan indicated a need for dependent toileting hygiene due to her self-care deficits. The facility's policy stated that residents have the right to privacy, including the use of privacy curtains during care, but this was not upheld during the observed incident.
Failure to Distribute Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents had timely access to their mail and privacy in their communications, as required by resident rights. Specifically, mail delivered to the facility on Saturdays was not distributed to residents until the following Monday. This practice was confirmed during a confidential resident council meeting, where all residents present stated they did not receive mail on Saturdays, even if it arrived. Multiple staff interviews corroborated that weekend mail was placed in a drawer and held until Monday for distribution by the social worker or activities department, rather than being delivered to residents on the day of arrival. A review of the facility's Resident Mail Policy indicated that mail delivered for residents should be given to the Activities Department and hand-delivered to resident rooms on the day of delivery. However, staff interviews revealed a lack of clarity and adherence to this policy, with some staff unaware of the requirement to distribute mail on Saturdays. This resulted in a failure to provide residents with their mail in a timely manner and did not uphold their right to privacy and access to communication.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Maintain Sanitary Conditions in Shared Shower Room
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program in the 3rd floor community shower room, which is used by up to 30 residents. Observations revealed that both shower stalls had drains clogged with large amounts of hair, a brown substance was present under one shower chair, and the floors were dirty with darkened areas and brown substance droppings in one of the stalls. Staff interviews confirmed that Certified Nursing Assistants (CNAs) were responsible for cleaning shower chairs between resident use, but one CNA reported only using shampoo to clean the chair due to a lack of disinfectant products. Housekeeping (Hsk) staff were responsible for cleaning the shower stalls and floors, but they left for the day by 4:00 PM, leaving cleaning duties to CNAs after that time. Further interviews with nursing and maintenance staff indicated confusion and inconsistency regarding cleaning responsibilities and procedures. The Assistant Director of Nursing (ADON) and Maintenance/Housekeeping Supervisor both described overlapping and unclear duties between CNAs and Hsk staff, particularly regarding the cleaning of feces and hair from drains. Policy documents reviewed stated that floors should be cleaned according to a schedule and that approved cleaning agents should be used in contaminated areas, but no specific policy for CNA responsibilities in cleaning and disinfecting shower rooms was provided. This lack of clear procedures and inadequate cleaning led to unsanitary conditions in the shared shower area.
Inadequate Supervision During Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision during the transportation of a resident, leading to an incident where the resident sustained an injury. The incident involved a male resident with end-stage renal disease, diabetes, osteoporosis, stroke, and seizure disorder, who used a manual wheelchair. On the day of the incident, the transportation driver did not safely transfer the resident onto the transportation van, resulting in the resident's foot getting caught in the gap where the ramp met the van, causing a sprain. The resident, who had intact cognition, reported immediate pain and swelling in his right ankle. The facility's records indicated that the resident's care plan included interventions to protect him from injury during transfers. Despite this, the transportation driver pushed the resident too quickly onto the van, leading to the injury. The facility's policy on transportation to and from off-site dialysis facilities was not effectively implemented, as evidenced by the lack of adequate supervision and safe transfer practices during the incident.
Failure to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain proper kitchen sanitation standards, specifically in the area of air vent cleanliness, which could lead to food contamination. During an observation, it was noted that five air conditioning vents over the food preparation area had accumulated fuzz and dust. This issue was identified as a potential risk for food contamination and food-borne illness due to the possibility of dust falling into the food. Interviews with various staff members revealed a lack of clarity and communication regarding the responsibility for cleaning the air vents. The kitchen staff and maintenance staff each believed the other was responsible for this task. The facility's policy on kitchen sanitation, which includes a comprehensive cleaning schedule, was not being followed, as evidenced by the lack of recorded cleaning tasks and unclear assignment of responsibilities. The Federal Food Code requires that non-food-contact surfaces, such as air vents, be kept free of dust and debris, a standard that was not met in this instance.
Failure to Report Incidents and Implement Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and exploitation of residents, as evidenced by three separate incidents involving residents. In the first incident, a resident with intact cognition and multiple medical conditions, including end-stage renal disease and osteoporosis, sprained his ankle when his foot got caught in the van ramp while being pushed by a transportation driver. Despite the resident experiencing significant pain and requiring an x-ray, the facility did not report the incident to the State Survey Agency as required by their policy. In the second incident, a resident with moderate cognitive impairment and a history of diabetes and stroke was found with ant bites on her body after ants were discovered in her bed. Although the facility treated the room and the resident reported no further issues, the incident was not reported to the State Survey Agency. The Director of Nursing (DON) did not consider the incident significant enough to warrant reporting, despite the facility's policy requiring such actions. The third incident involved a resident with severe cognitive impairment who was mistakenly given the wrong medications, including a narcotic pain pill and Xanax, instead of their prescribed medications. The error was recognized by the administering LVN, who notified the doctor and the DON. The resident was monitored for 72 hours and experienced no adverse effects. However, the incident was not reported to the State Survey Agency, as the DON and Operations Manager did not believe it met the criteria for reporting, despite the facility's policy indicating otherwise.
Inadequate Use of PPE in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not donning appropriate Personal Protective Equipment (PPE) while providing care to two residents on Enhanced Barrier Precautions (EBP). Resident #57, a cognitively intact female with a colostomy due to spinal bifida and paraplegia, was observed receiving care from a CNA who only wore gloves, despite signage indicating the need for both gown and gloves. Similarly, Resident #185, a male with severe cognitive impairment and an indwelling catheter, received care from an LVN and a CNA who also failed to wear gowns, contrary to facility policy. Interviews with the involved staff revealed a lack of awareness regarding the necessity of wearing gowns, despite recent in-service training on infection control and clear signage. The Infection Preventionist and the Director of Nursing acknowledged the oversight, noting that PPE was readily available and emphasizing the risk of spreading infections due to improper PPE use. The facility's policy on Enhanced Barrier Precautions, which mandates gown and glove use during high-contact care activities, was not adhered to, leading to this deficiency.
Failure to Report Incidents to State Survey Agency
Penalty
Summary
The facility failed to report several incidents to the State Survey Agency as required by state law. One incident involved a resident who sprained his ankle when his foot got caught in the van ramp while being pushed by a transportation driver. Despite the resident experiencing significant pain and requiring an x-ray to rule out fractures, the incident was not reported to the State Survey Agency. The resident's care plan included interventions to protect him from injury due to his osteoporosis, yet the incident occurred during a routine transport to dialysis. Another incident involved a resident who was found with ant bites on her body. The resident, who had moderate cognitive impairment and required total assistance with most activities of daily living, was discovered with sugar ants all over her bed. Although the facility treated her room and the resident reported no further issues, the incident was not reported to the State Survey Agency. The facility's pest control logs indicated regular treatments for ants, but the incident was deemed not significant enough to report by the Director of Nursing. A third incident involved a resident who was given the wrong medications. The resident, who had severe cognitive impairment and multiple health conditions, was mistakenly administered a narcotic pain pill and Xanax instead of his prescribed medications. The error was recognized, and the resident was monitored for any adverse reactions, but the incident was not reported to the State Survey Agency. The Director of Nursing and the Operations Manager, who were responsible for reporting such incidents, did not report it as they believed there was no harm to the resident.
Failure to Maintain Resident's Bed in Working Condition
Penalty
Summary
The facility failed to maintain Resident #8's bed in proper working condition, which could potentially place residents at risk for skin tears, injury, falls, and discomfort during transfers. Resident #8, a [AGE] year-old female with intact cognition and active diagnoses including biliary cirrhosis, chronic pain syndrome, and fibromyalgia, required assistance with bed mobility and transfers. Despite her need to elevate her legs due to edema, the bed's end was not functioning, and the resident had reported this issue to staff and maintenance without resolution. Interviews with staff, including a CNA, RN, DON, Operations Manager, and Maintenance Director, revealed a lack of communication and follow-up regarding the bed's malfunction. The CNA had informed the Maintenance Director, who checked the bed but was unaware of the specific issue with the end of the bed. The facility had an online system for logging maintenance concerns, but no work orders were found for Resident #8's bed. The facility's policy required maintenance issues to be reported and resolved within 72 hours, but this was not adhered to in this case.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a deficiency related to pest infestation. A resident reported that her bed was infested with ants, leading to numerous bites on her arms and legs. The resident, who had moderate cognitive impairment and required total assistance with most activities of daily living, experienced this issue, which was documented in nursing notes. The Director of Nursing (DON) did not report the incident, as they did not consider it significant enough, despite the resident's visible symptoms and the need for medical intervention. Additionally, the facility's kitchen was observed to have multiple gnats in the food preparation, storage, and dishwasher areas. Staff were seen waving their hands to move the gnats while preparing food, indicating an ongoing issue. Interviews with staff revealed that pest control services were conducted once or twice a month, but the problem persisted. The facility's pest control logs and invoices confirmed regular treatments, yet the presence of pests in the kitchen continued, posing a risk of cross-contamination of food.
Failure in PASRR Screening for Mental Illness
Penalty
Summary
The facility failed to ensure that a new resident was not admitted with a mental disorder without the appropriate evaluation by the state mental health authority. Specifically, the Social Worker did not accurately complete the Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident who had been diagnosed with schizoaffective disorder, schizophrenia, and depression. The resident's Minimum Data Set (MDS) and care plan indicated these diagnoses, yet the PASRR Level 1 screening incorrectly marked 'NO' for the presence of a mental illness. The Social Worker admitted to not reviewing the resident's clinical records prior to admission, which led to the oversight of the resident's schizophrenia diagnosis. This oversight meant that the resident was not referred for a PASRR Level II evaluation, which could have identified the need for specialized services. The facility's policy requires that all residents with a positive PASRR Level 1 screening must have a PASRR Level II evaluation or documented attempts to obtain one, which was not followed in this case.
Neglect in G-Tube Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications associated with enteral feeding. Specifically, the facility did not provide the necessary g-tube care for a resident, as per physician orders. The resident, an elderly female with severe cognitive impairment and a history of dysphagia following a stroke, was observed without a dressing on her g-tube stoma, which had yellow exudate present. Despite the presence of a g-tube, the resident was able to eat and take medications orally, leading to the neglect of g-tube care. The nurse assigned to the resident admitted to not providing the required g-tube care, despite documenting that the care was completed. The nurse, who had been employed for four weeks and was working independently for only the second day, was unaware of the specific orders for g-tube care. This oversight was attributed to the resident's ability to eat by mouth, which led to the g-tube care not being prioritized. The nurse acknowledged the risk of infection due to the lack of g-tube care. Interviews with the ADON and DON revealed that they were unaware of the lapse in g-tube care for the resident. The facility had a system in place for weekly checks of residents' g-tubes, but the ADON could not recall if the resident's g-tube was checked during the last round. Both the ADON and DON emphasized the importance of following physician orders to prevent infections, highlighting a gap in the facility's adherence to its own policies and procedures regarding g-tube care.
Medication Error Due to Distraction
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was administered incorrect medications. The resident, a male with severe cognitive impairment and multiple active diagnoses including chronic obstructive pulmonary disease, dysphagia, gastro-esophageal reflux disease, type 2 diabetes mellitus with diabetic neuropathy, and essential hypertension, was supposed to receive Pantoprazole Sodium Delayed Release 40 mg and Tramadol HCl 50 mg. Instead, he was given Alprazolam 0.5 mg and Hydrocodone-Acetaminophen 10-325 mg, which were intended for another resident. The error occurred when LVN A, who was responsible for administering the medications, became distracted by a staff member's question while preparing another resident's medication. This distraction led to the administration of the wrong medications to the resident. The resident was monitored for any adverse reactions, but fortunately, he did not exhibit any side effects or allergic reactions to the medications administered in error. Interviews with the involved staff, including LVN A, the ADON, and the DON, confirmed the occurrence of the medication error. LVN A acknowledged the mistake and reported it immediately to the physician and the DON. The facility's policy on medication administration emphasizes the importance of identifying residents prior to medication administration and documenting each medication order accurately, which was not adhered to in this instance.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature level in a resident's room, which is a violation of the resident's right to a safe, clean, comfortable, and homelike environment. The resident, a male with a history of hypertension, anxiety disorder, and chronic obstructive pulmonary disease, reported that his room had been uncomfortably hot for some time. Despite having a fan, the room temperature remained high, reaching 80 degrees Fahrenheit during an observation. Subsequent checks showed the temperature increased to 82 degrees Fahrenheit. The Maintenance Assistant was informed multiple times by the resident about the malfunctioning air conditioning unit, but the issue persisted. The Maintenance Assistant claimed that the air conditioning unit was functioning properly, as the temperature from the vent was 66 degrees Fahrenheit. However, the room temperature remained high. The Maintenance Director was only made aware of the issue on the day of the survey, and an AC repairman was called to address the problem. The Operations Manager was not informed of the issue until the survey, highlighting a communication breakdown within the facility.
Failure to Document G-Tube Care Accurately
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of g-tube care. The resident, an elderly female with severe cognitive impairment and a history of dysphagia following a stroke, was observed to have a g-tube for nutritional support. However, the Licensed Vocational Nurse (LVN) assigned to her care did not accurately document the g-tube care as required by the physician's orders. The LVN admitted to not providing the necessary care and falsely documenting that the care was completed. The LVN, who had been employed for four weeks and was working independently for only the second day, was unaware of the specific orders for g-tube care. Despite this, she documented on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) that the care was provided. This discrepancy was discovered during an observation and interview, where it was noted that the g-tube site had yellow exudate and no dressing, although the resident did not report pain or discomfort. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that they were unaware of the lapse in care until it was brought to their attention. Both acknowledged that the failure to accurately document care constitutes falsification of records. The facility's policy requires that medications and treatments be administered only upon clear and complete orders, and that documentation must be accurate, which was not adhered to in this case.
Resident Elopement Due to Inadequate Supervision and Alarm Failure
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in an elopement incident involving a resident. The resident, who had severe cognitive impairment and was identified as an elopement risk, managed to leave the facility undetected. The incident occurred when the resident walked past the nurses' station, took the elevator from the third floor to the first floor, and exited the building. Although the alarm system was functional, it was not heard by the staff, allowing the resident to leave the premises. The resident was found at a gas station approximately a quarter of a mile from the facility by the police and returned unharmed. The resident was unable to verbalize the reason for leaving the facility. Prior to the incident, the resident had not shown any inclination to leave the facility and was able to verbalize his needs and be easily redirected by staff. The resident's care plan had identified him as an elopement risk, but the measures in place were insufficient to prevent the incident. Interviews with staff revealed that the charge nurse was the last to see the resident before the elopement, and the maintenance director confirmed that the alarm system was working but not heard. The facility's failure to prevent the elopement placed residents at risk of harm, serious injury, or death, and the incident was identified as a past non-compliance Immediate Jeopardy situation.
Infection Control Lapse During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a CNA during the care of a resident. The CNA did not change gloves or wash hands after touching the privacy curtain and before providing incontinent care to the resident. Additionally, the CNA failed to sanitize hands between glove changes after cleaning the resident's genitals and buttocks, which is a breach of standard infection control practices. These actions were observed during a specific incident involving a resident with a history of urinary tract infections and other medical conditions, who required extensive assistance with daily living activities. Interviews with the CNA and the Director of Nursing (DON) confirmed the lapses in infection control practices. The CNA acknowledged not changing gloves or washing hands as required, despite having received infection control training within the year. The DON confirmed that staff should change gloves and sanitize hands to prevent contamination and infection. The facility's nurse aide competency checklist indicated the need for hand hygiene and glove changes during perineal care, but there was no specific policy regarding these practices during incontinent care.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for a resident reviewed for medication administration. Specifically, the facility did not administer the prescribed Alprazolam Oral Tablet 0.5 MG to the resident as ordered by the physician. The resident missed several doses of the medication on multiple occasions due to a delay in delivery from the hospice provider and a lack of proper follow-up by the facility staff to ensure the medication was available and administered on time. The resident, who was cognitively intact with a BIMS score of 14, had a history of quadriplegia, muscle weakness, myocardial infarction, schizoaffective disorder, psychotic disorder, major depression, pain, and anxiety. The resident's care plan included administering medications as ordered. However, the resident did not receive his scheduled doses of Alprazolam on 3/21/2024 at 2:00 PM, and on 3/22/2024 at 6:00 AM and 2:00 PM. The facility staff documented that they were in contact with the hospice provider to obtain the medication, but there was a failure in ensuring the medication was delivered and administered in a timely manner. Interviews with facility staff and the hospice nurse revealed that there was a miscommunication and lack of proper coordination between the facility and the hospice provider. The hospice nurse confirmed that their agency had no record of being notified to fill the prescription before the resident ran out of medication. The facility's policy stated that medications should be administered as prescribed by the attending physician, but this was not adhered to in this case, leading to the resident missing critical doses of his anti-anxiety medication.
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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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