St. Teresa Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 10350 Montana Avenue, El Paso, Texas 79925
- CMS Provider Number
- 676342
- Inspections on file
- 60
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at St. Teresa Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia, schizophrenia, and anxiety, but assessed as cognitively intact on the MDS, reported that cash was missing from her purse, which she kept on a lamp beside her bed, and stated she had told the ADON and was later informed she would be reimbursed. The BOM confirmed that missing-money allegations should be investigated by the abuse coordinator and possibly reported to the state, and found no related activity in the resident trust account. The ADON reported that an LVN had relayed the resident’s allegation that $60 was stolen, that she notified the Administrator, and that such allegations should be investigated and reported. The Administrator acknowledged receiving the report, stated the resident gave inconsistent details and described the money as misplaced, and admitted she did not document or conduct an investigation or report the allegation, instead treating it only as a grievance, contrary to the facility’s abuse/misappropriation policy.
A resident with diabetes, CHF, COPD, hypertension, and hyperlipidemia, who was cognitively intact and received insulin injections several times per week, was observed in bed with a tracheostomy while an empty syringe was found left unattended on top of the dresser in the room. The syringe was within reach of anyone entering and had not been discarded in a sharps container as required. Multiple CNAs, LVNs, and ADONs stated that sharps, including syringes, must be disposed of immediately after use in designated sharps containers, and facility infection control and standard precautions policies likewise required immediate disposal of used sharps in puncture-resistant, leak-proof containers located near points of use. The observed unattended syringe in the resident’s room was inconsistent with these established practices and policies, resulting in the cited deficiency.
A resident with multiple comorbidities and poor cognition was receiving ordered IV hydration when an LVN attempted an IV insertion without consistently following aseptic technique or standard precautions. The IV tubing was placed on visibly soiled linens, the IV needle was set on the bed causing blood-stained linens and then moved to the bedside table, and the LVN removed gloves and continued the procedure, including connecting and removing the IV catheter and handling the needle, with bare hands. Interviews with the LVN, ADON, DON, and Administrator showed that these actions were inconsistent with facility policies requiring proper PPE use, immediate sharps disposal in appropriate containers, hand hygiene, and prompt handling of contaminated linens, and also revealed gaps in in-person IV training and inconsistent adherence to infection control policies.
The facility failed to maintain complete and accurate medical records and to submit detailed Provider Investigation Reports (PIRs) to HHSC for incidents involving two residents with significant cognitive and medical conditions. For one bedbound resident with dementia and a history of falls, documentation noted ankle swelling and later a fracture, but the trauma-informed assessment showed no negative findings and the chart lacked clear documentation of investigative steps and interventions such as pain management, therapy evaluation, and compression. For another resident with DM2, cerebrovascular disease, anoxic brain damage, and sarcopenia, PIRs similarly lacked detail on interviews, records reviewed, and interventions. The DON and Administrator stated that interviews and interventions occurred, but acknowledged that PIRs were vague and that the Administrator kept investigative notes in a personal notebook instead of in the medical record or PIR, contrary to policy and HHSC requirements for thorough, documented investigations.
Surveyors found that the facility failed to update a comprehensive, person-centered care plan after a resident with dementia and severe cognitive impairment experienced a fall. The resident’s care plan identified general fall risk and listed standard fall-prevention interventions, but did not address the specific in-facility fall as a change of condition. The MDS nurse, DON, and Administrator all acknowledged that such a fall should have been added to and updated in the care plan, consistent with facility policy requiring comprehensive care plans with measurable objectives and timeframes that are revised with significant changes in condition.
A resident with multiple Stage 4 pressure ulcers and significant comorbidities received wound care from a Wound Care RN who applied Arginaid powder directly to buttock wounds, allowing the powder to spill onto the resident’s brief and then securing the soiled brief without changing it. The resident had physician orders for daily and PRN wound care and a care plan including wound care and Arginaid, and prior documentation indicated the wounds were healing without signs of infection. The DON later stated that wound care must follow facility policy and acknowledged that leaving a brief with spilled medication in place was not acceptable and could cause infection, while the facility’s wound treatment policy required treatments per orders and dressing changes when dressings are soiled or wet.
Two residents with indwelling Foley catheters did not receive proper catheter securement or perineal care, as Catheter Holders were found loose or detached and perineal cleaning was performed from back to front instead of front to back, contrary to facility policy and staff training. Both residents had significant medical histories requiring careful catheter management, but care plans and observed practices did not consistently address or follow required procedures.
A resident with multiple complex medical conditions, including ventilator dependence and a persistent vegetative state, was issued a 30-day discharge notice for non-payment, but the facility failed to initiate or develop a discharge plan at that time. The care plan lacked discharge planning, and staff interviews confirmed that no steps were taken to assess or coordinate the resident's post-discharge needs, especially during a period when the facility was without a social worker.
A facility failed to employ a qualified full-time social worker, resulting in lapses in grievance handling and discharge planning for a resident with complex medical needs, including ventilator dependence and multiple chronic conditions. During the vacancy, administrative and nursing staff attempted to cover social work duties, but discharge planning and grievance documentation were not consistently completed according to policy.
A resident with a wound and indwelling medical devices did not receive Enhanced Barrier Precautions (EBP) during high-contact care activities, despite staff training, available PPE, and posted signage. Staff failed to don gowns and gloves or perform hand hygiene before direct care, and the care plan and physician orders did not document EBP requirements. Staff interviews revealed confusion about EBP necessity and lapses due to being rushed, contrary to facility policy.
Two residents with cognitive impairments were involved in a physical altercation when one resident entered another's room and was struck in the face and had items thrown at her, resulting in visible bruising. Staff intervened after hearing yelling and found the scene with scattered belongings and spilled water. Both residents had no prior history of aggression, but the incident revealed a failure to prevent abuse and ensure resident safety.
A resident with a history of nutritional deficiency and protein-calorie malnutrition was not provided with the correct enteral feeding rate as ordered. The resident was supposed to receive Isosource 1.5 at 50 ml/hr, but the feeding pump was set to 65 ml/hr. The DON admitted to not following up on the order change, and the dietician had concerns about caloric intake. The resident's weight increased slightly, but the PCP noted no health risk.
A facility failed to maintain accurate inventory records for a resident with dementia, leading to a grievance about a missing blanket. The DON confirmed the grievance, and staff interviews revealed inconsistencies in inventory procedures. The facility's policy required documentation of sentimental items, which was not followed.
A resident with respiratory issues and a BiPAP order did not have the use of the BiPAP machine included in their care plan. Despite physician orders and consistent monitoring of oxygen saturation levels, the care plan only addressed oxygen therapy. Interviews with facility staff revealed that the omission was an oversight, with responsibilities for updating care plans acknowledged by the DON, MDS Coordinator, and Administrator.
Two residents in the facility, both requiring assistance with ADLs, were found with long and dirty fingernails, indicating a failure in providing necessary personal hygiene care. One resident, with dementia and hemiplegia, was dependent on staff for nail care, which was overlooked despite regular bathing schedules. Another resident, with tracheostomy and gastrostomy status, also had long, jagged nails, posing a risk of self-injury. Staff interviews revealed a lack of awareness and communication regarding nail care responsibilities, contrary to the facility's policy.
A facility failed to properly label a resident's enteral feeding bag, risking inadequate nutrition. The resident, with a history of gastro-esophageal reflux disease and malnutrition, was on continuous g-tube feeding. The DON confirmed the labeling requirement, and the LVN admitted to not labeling the bag due to an interruption, acknowledging the risk of incorrect feeding and monitoring issues.
The facility failed to properly handle advance directives for residents, specifically DNR orders. A resident's DNR request was pending a physician's signature, and there was no scanned document in the records. Another resident's OOH DNR was not signed by a physician, and the process was incomplete. The facility began the enactment process, but the document was scanned before being signed, resulting in an incomplete DNR status.
The facility failed to ensure that residents were not given psychotropic drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. A resident received Risperidone for Delusional disorder without indicators of psychosis, another was prescribed Aripiprazole for depression despite no symptoms, and a third received Quetiapine for dementia without psychosis. The DON acknowledged the inappropriate use of these medications.
A long-term care facility failed to maintain an effective infection prevention and control program. A resident with Shingles was placed under incorrect precautions, lacking necessary airborne measures. Additionally, urinary catheters for three residents were improperly maintained, with bags found on the floor, increasing infection risk. Staff interviews revealed a lack of adherence to facility policies, contributing to these deficiencies.
A deficiency was identified involving the improper maintenance of oxygen machines, specifically the checking of oxygen filters. The DON was informed that the RT is responsible for ensuring the machines function properly. This oversight risks the resident not receiving adequate oxygen, increasing the risk of infection.
A facility failed to ensure a resident was free from physical restraints not required for medical symptoms. A concave mattress was used without assessment, physician's order, or consent, despite the resident's difficulty in getting out of bed. The DON concluded the mattress was not a restraint, but facility policy required a physician's order and consent for restraints.
A facility failed to implement a comprehensive care plan for a resident, omitting interventions for several medical and psychosocial needs, including urinary tract infection, shortness of breath, and depression. The care plan also lacked specific goals for self-care deficits. Staff interviews revealed a lack of personalization and a system to identify incomplete care plans, potentially risking unmet care needs.
Two residents in an LTC facility were found with long fingernails, indicating a failure to provide necessary grooming and hygiene services. Both residents had significant medical histories and required assistance with ADLs. Staff interviews revealed that nail care was supposed to be performed during showers, but this was not consistently done, leading to a deficiency in maintaining proper hygiene.
A resident with limited range of motion did not receive adequate treatment and services to maintain or improve her condition. Despite having moderate cognitive impairment and requiring assistance for daily activities, her care plan lacked specific interventions for range of motion. The facility's restorative program was suspended, and there was no clear process for monitoring changes in residents' functioning, leading to a deficiency in care.
A resident with paralysis and high fall risk experienced a fall due to inadequate supervision and improper use of a mechanical lift by staff. The staff demonstrated incorrect transfer techniques, including jerking the lift over fall mats, which posed a risk of injury. The facility's training and supervision were insufficient to ensure safe transfers.
A deficiency was identified when a resident's urinary catheter bag was found resting on a fall mat, contrary to infection control protocols. A staff member confirmed the improper placement, and the DON admitted to not knowing the policy on privacy bag sufficiency, acknowledging a potential infection risk. All clinical staff are responsible for catheter care.
Two residents receiving oxygen therapy were found with dusty oxygen concentrator filters, despite orders for regular maintenance. Staff interviews revealed confusion over responsibility for filter upkeep, risking inadequate oxygen delivery and respiratory issues.
A resident did not receive the prescribed multivitamin with minerals due to an LVN administering the wrong supplement. Additionally, expired insulin pens were found in two medication carts, indicating a failure in medication storage management. The DON and Administrator acknowledged these deficiencies, which were contrary to the facility's pharmacy policy.
A deficiency was identified in a LTC facility regarding medication administration and storage. An LVN administered a multivitamin without minerals to a resident, contrary to the physician's order, and failed to report the unavailability of the correct medication. Additionally, expired insulin pens were found in medication carts, indicating lapses in monitoring and disposal practices. The DON and Administrator acknowledged these failures, which could affect the efficacy of resident treatments.
The facility failed to maintain accurate DNR documentation for three residents. A resident's DNR status was recorded without a completed Texas OOH DNR form, another resident was listed as DNR without the necessary form, and a third resident's DNR form lacked a physician's signature. The facility's policy was to treat residents as DNR based on a signed request form, even if the official documentation was incomplete.
A resident's family reported a privacy violation during perineal care, as CNAs left the curtain open, exposing the resident to her roommate. Despite being informed, the Weekend Supervisor and ADON did not initiate a formal grievance, failing to document or investigate the issue as per the facility's policy.
Two residents requiring assistance with ADLs were found with long, jagged fingernails, indicating a failure in personal hygiene care. One resident, with Parkinson's and other medical conditions, was dependent on staff for hygiene, yet his nails were neglected. Another resident, cognitively intact but requiring max assistance, expressed dissatisfaction with his nail care. Interviews with staff revealed inconsistencies in nail care responsibilities, despite a facility policy emphasizing regular nail management.
A resident with Parkinson's disease and other medical conditions was found with their call light out of reach, tangled under a monitor, preventing them from contacting staff for assistance. Despite the care plan's requirement to keep the call light accessible, staff interviews confirmed the oversight, highlighting a deficiency in ensuring resident needs are met.
A resident's privacy was compromised when two CNAs provided perineal care without closing the curtain, allowing the roommate to potentially view the care. The resident, who was severely cognitively impaired and dependent on toileting, had a history of vascular dementia, cerebral infarction, and tracheostomy status. Despite training on privacy, the CNAs involved were not identified, and the incident was reported by the resident's responsible party.
A resident with multiple diagnoses, including dementia and seizures, required two-person assistance for bathing as per their care plan. However, a CNA bathed the resident alone due to pressure to complete showers, risking injury. Facility policies and interviews with staff confirmed the need to follow care plans for safety, but the care plan was not adhered to, placing the resident at risk.
A facility failed to replace a resident's tracheostomy ventilation circuit tubing that contained red/brownish particles for two days. The resident, who had vascular dementia and tracheostomy status, was observed with the contaminated tubing without showing distress. Interviews revealed that the RT did not notice the particles, and the DON confirmed that the equipment should be checked and replaced as needed, placing the resident at risk of infection.
A resident with severe cognitive impairment and muscle weakness fell and sustained a laceration after a CNA provided perineal care without the required two-person assistance. Despite knowing the resident's care plan, the CNA chose to perform the task alone, leading to the fall and injury.
The facility failed to ensure proper catheter care for two residents, leading to potential risks of infection. One resident's urinary catheter was mishandled, causing urine spillage, while another resident did not receive required catheter care every shift as indicated in their care plan.
The facility failed to document a COVID-19 positive resident in the Infection Control Log and a CNA did not change gloves after cleaning a resident's BM, continuing ADL assistance with dirty gloves. These actions violated infection control protocols and placed residents at risk for infection.
The facility failed to document physician orders for a resident who was Covid-19 positive and placed in isolation. Despite detailed care instructions in the resident's care plan, the necessary physician orders were missing, as confirmed by both an LVN and the DON.
Failure to Investigate and Report Allegation of Misappropriation of Resident Money
Penalty
Summary
The deficiency involves the facility’s failure to investigate and report an allegation of misappropriation of resident property in accordance with its abuse/neglect policy. A cognitively intact female resident with dementia, schizophrenia, anxiety disorder, and a history of brain hemangioma and seizure disorder reported that money had been stolen from her purse, which she routinely kept on top of a lamp beside her bed. During an observation and interview, the resident stated she could not recall the exact amount or date of the missing money but reported feeling anxious and upset after discovering it was gone. She stated she had informed the ADON of the missing money and was later told by an unidentified front office staff member that the facility would reimburse her by depositing funds into her resident account. Interviews with staff confirmed that the allegation was reported internally but not handled as required by facility policy. The BOM stated that allegations involving missing money required investigation by the abuse coordinator and possible reporting to the state, and that review of the resident’s trust account showed no related deposits or withdrawals. The ADON reported that an LVN had informed her that the resident alleged $60 in cash had been stolen from her purse, and that she in turn informed the Administrator and spoke with the resident’s representative about reimbursement using facility fundraising money. The ADON stated that the Administrator, who served as the abuse coordinator, assumed responsibility for the investigation and that such allegations should be investigated through interviews with residents and staff and reported to the state. The Administrator acknowledged receiving the report of missing money and speaking with the resident, but stated the resident gave varying information about the amount and details and reported misplacing, rather than having money stolen. The Administrator stated she would have conducted a full investigation and reported the matter to the state only if the resident had specifically alleged theft by another individual. She admitted she did not document an investigation, did not interview residents or staff about finding money, and treated the matter solely as a grievance. This response did not comply with the facility’s written policy, which requires that all allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property be promptly reported, thoroughly investigated by the Administrator or Abuse Preventionist, and reported to HHSC when criteria are met.
Unattended Syringe Left in Resident Room Contrary to Sharps Disposal Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the resident environment remained as free of accident hazards as possible and that residents received adequate supervision to prevent accidents. During an observation in a resident’s room, surveyors found an empty syringe left unattended on top of the resident’s dresser, within reach of anyone entering the room. The resident was in bed with a tracheostomy tube in place and was unable to speak, but nodded slightly when asked if she received insulin medications. The syringe was not disposed of in a sharps container as required by facility policy and standard precautions. Record review showed the resident was an adult female with an admission history including type 2 diabetes mellitus, congestive heart failure, COPD, hypertension, and hyperlipidemia. The quarterly MDS documented a BIMS score of 14, indicating she was cognitively intact, and confirmed an active diagnosis of diabetes mellitus. The MDS also indicated that she received insulin injections five days per week since admission or reentry, and her care plan included interventions for diabetes management such as administering diabetes medications as ordered and monitoring blood glucose levels. Multiple staff interviews, including with ADONs, CNAs, and LVNs, confirmed that facility practice and expectation were that all sharps, including syringes and needles, must be discarded immediately after use into designated sharps containers located on medication carts or in designated areas. Staff consistently stated that leaving syringes in resident rooms was not acceptable and described them as sharps and biohazardous items that must be promptly disposed of. Review of the facility’s written policies on Fundamentals of Infection Control Precautions and Standard Precautions further documented that used sharps are never to be recapped and must be discarded immediately in puncture-resistant, leak-proof sharps containers that are readily accessible where sharps are used. The presence of the unattended syringe in the resident’s room was inconsistent with these policies and staff statements, leading to the cited deficiency.
Improper PPE Use and Sharps Handling During IV Insertion
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during IV therapy for one resident. The resident was an elderly female with multiple diagnoses including diabetes mellitus, hyperkalemia, malnutrition, a displaced intertrochanteric fixation of the left femur, constipation, muscle weakness, overactive bladder, dysphagia, hypothyroidism, cognitive communication deficit, vitamin D deficiency, and a history of myocardial infarction. Her Quarterly MDS showed a BIMS score of 3, indicating poor cognitive status. She had active physician orders for IV sodium chloride infusions every shift for hydration, and her care plan included participation in an IV therapy infusion program. During an observed IV insertion attempt by an LVN, aseptic technique and standard precautions were not consistently followed. The IV tubing was placed on the resident’s sheets and blanket before administration, and the linens were visibly soiled with stains. The LVN inserted an IV catheter into the resident’s left wrist while wearing gloves that had a visible opening. After insertion, the IV needle was placed on the resident’s bed, causing blood to stain the linens, and then the needle was picked up and placed on the bedside table. The LVN removed her gloves, discarded them, and then connected the IV tubing to the catheter without wearing gloves. When it was determined that the IV was not properly placed, the catheter was removed without gloves. The LVN then handled the IV needle with bare hands and disposed of items into the resident’s trash before finally placing the needle into the sharps container and performing hand hygiene. Interviews with staff and leadership showed that the observed practices were inconsistent with facility policies and stated expectations. The LVN stated she only had one pair of gloves during the procedure and acknowledged that sharps such as needles and razors were to be placed in sharps containers and handled with gloves, but also reported she had not received in-person IV insertion training at the facility and had only completed online IV training. The ADON stated that gloves should be used for IV initiation, sharps should be handled safely and disposed of in sharps containers, contaminated linens should be changed immediately, and that policies were not consistently followed. The DON stated that gloves were to be consistently used, sharps disposed of immediately in sharps containers, staff were expected to have all necessary supplies available before starting procedures, and that based on the information provided, policies were not followed. The Administrator stated that syringes should not be left in resident rooms, sharps should be capped and placed in sharps containers after use, gloves were typically available in rooms, and that she was aware policies existed but could not recall them specifically or provide information on infection control training. Facility policies on standard precautions and infection control required hand hygiene, appropriate glove use, immediate disposal of contaminated sharps in puncture-resistant containers, and proper handling and bagging of soiled linens, which were not adhered to during the observed IV procedure. The facility’s written policies titled “Standard Precautions” and “Fundamentals of Infection Control Precautions” specified that handwashing is necessary after contact with blood or contaminated items and after glove removal, that gloves should be worn when touching blood and body fluids and during invasive procedures, and that gloves should be changed between resident contacts. The policies also required that needles not be bent or broken by hand, that contaminated sharps not be recapped using a two-handed technique, and that sharps containers be readily accessible, puncture-resistant, leak-proof, and not more than two-thirds full. Contaminated work surfaces were to be disinfected immediately, and all soiled linen was to be bagged at the site of use, handled as little as possible, and treated as potentially infectious. The policies further emphasized that used sharps are never recapped and must always be placed in puncture-resistant containers, and that consistent use of appropriate infection control measures, including PPE and hand hygiene, is required when caring for residents with vascular access catheters. The observed actions during the IV insertion for this resident did not conform to these written standards.
Incomplete Medical Records and Vague Provider Investigation Reports for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and to provide accurate, detailed self-reports to HHSC for incidents involving two residents. For one resident, an elderly female with hypertension and dementia and a BIMS score indicating severe cognitive impairment, documentation showed an event note on 12/25/25 indicating ankle swelling with no pain reported and notification of the physician and responsible party. However, the trauma-informed PRN assessment documented no negative findings, despite the prior observation of swelling and the later discovery of an ankle fracture. The Administrator later stated the resident was bed bound, had a history of falls, and that CNAs observed swelling while showering the resident, but these investigative details and related interventions were not reflected in the resident’s chart or in the formal investigation documents. For the second resident, an elderly female with type 2 diabetes mellitus, cerebrovascular disease, anoxic brain damage, and sarcopenia, records showed significant cognitive and physical impairments, including inability to participate in the BIMS. The Provider Investigation Reports for incidents involving both residents lacked detailed information such as which staff and residents were interviewed, what documentation was reviewed, and what specific interventions were implemented to address or prevent further incidents. The DON reported that staff, including CNAs, nurses, the residents, and therapy staff, were interviewed as part of the investigations and that interventions such as pain medication management, therapy evaluation, and compression were implemented for the first resident after her fall, but these actions were not clearly documented in the investigation reports. Interviews with the DON and Administrator confirmed that the Provider Investigation Reports submitted to HHSC were vague and did not include the interventions or investigative steps they described verbally. The Administrator acknowledged that she documented her investigative findings in a personal notebook rather than in the residents’ medical records or in the Provider Investigation Reports, and that this information was not incorporated into the official documentation sent to HHSC. Facility policy and HHSC guidance require that comprehensive investigations be conducted and documented in the Provider Investigation Report, including the nature and extent of injuries, subsequent negative outcomes, and other pertinent information, but the reports reviewed did not meet these standards.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes addressing a resident’s fall that occurred in the facility. The resident was an elderly female with hypertension and dementia, with a BIMS score of 7 indicating severe cognitive impairment, initially admitted in mid-November and readmitted in late December. Record review showed that although the resident’s care plan, revised at the end of January, identified her as being at risk for falls related to impaired mobility and listed general fall-prevention interventions (such as anticipating needs, keeping the call light within reach, and educating resident/family/caregivers about safety and what to do if a fall occurs), it did not include the specific fall event that occurred on 12/25/25. Observation on 02/03/26 found the resident in bed in the lowest position with the call light within reach, and she did not respond to the surveyor’s questions about the facility’s care or services. Interviews with facility staff confirmed that the fall should have been incorporated into the resident’s care plan as a change of condition. The MDS nurse stated that a fall is considered a change of condition that must be added to and updated in the care plan, that care plans are individualized to inform staff how to provide care, and that ADONs are responsible for making acute changes while MDS nurses review care plans quarterly or as needed for significant changes. The DON similarly stated that the fall was a change of condition that should have been included in the care plan and that nursing staff are responsible for monitoring and updating care plans for acute changes, with MDS nursing reviewing care plans quarterly and monitoring daily. The Administrator stated that the care plan is intended to paint a picture of residents’ needs and provide information to all staff, and that care plans are reviewed quarterly by MDS nursing and updated immediately by nursing staff when there is a change of condition. The facility’s undated Comprehensive Care Planning policy stated that the facility will develop and implement a comprehensive care plan for each resident, consistent with resident rights, including measurable objectives and timeframes to meet identified needs, and that care plans will be reviewed and revised after admission, quarterly, annually, and/or with significant change MDS assessments and in response to current interventions.
Improper Wound Care and Infection Control During Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and maintain infection prevention and control practices for a resident on transmission-based precautions with multiple Stage 4 pressure ulcers. The resident was an elderly female with a history of Type 2 diabetes mellitus, cerebrovascular disease, anoxic brain damage, and sarcopenia, who was unable to participate in the BIMS and unable to answer questions due to her medical condition. Her physician orders required daily and PRN wound care for Stage 4 pressure wounds on the left buttock, right buttock, and sacrum, and her care plan included wound care and administration of Arginaid as ordered. A wound care progress note documented that all wound sites were healing with no signs of infection. During an observation of wound care, the Wound Care RN applied Arginaid, a powder-form nutritional supplement, directly onto the resident’s right and left buttock wounds. The powder was observed spilling from the wounds onto the resident’s brief. The Wound Care RN then secured the brief on the resident without changing it, leaving the spilled medication on the brief. In a subsequent interview, the DON stated that wound care nurses were responsible for providing wound care per facility policy and that it was not acceptable for the Wound Care RN to leave a brief on the resident with contaminated spilled medication, acknowledging that this could lead to possible infection or illness and could infect the resident’s other wounds. The facility’s wound treatment management policy stated that wound treatments would be provided in accordance with physician orders and that dressing changes may be provided outside the usual frequency when the dressing is soiled or otherwise wet.
Failure to Provide Proper Catheter Securement and Perineal Care
Penalty
Summary
The facility failed to provide appropriate care for residents who were incontinent of bowel and bladder, specifically in the areas of catheter care and perineal hygiene, as observed in two residents. Both residents had indwelling Foley catheters and were dependent on staff for all activities of daily living, including toileting and hygiene. Observations revealed that the catheter drainage tubes for both residents were not properly secured with a Catheter Holder prior to turning and repositioning in bed. The Catheter Holders were found to be loose or detached, and staff interviews confirmed that this was a recurring issue, particularly after showers or when lotion was applied. Staff were aware of the need to report and replace detached Catheter Holders, but this was not consistently done in practice. In addition to issues with catheter securement, perineal care was not performed according to facility policy for one resident. During an observed episode of incontinence care, a CNA cleaned the perineal area from back to front, rather than from front to back as required by policy and training. This method of cleaning increases the risk of cross-contamination from fecal matter to the urethral and vaginal areas. The CNA used multiple wipes but did not adhere to the correct technique, despite having been trained on the proper procedure. Interviews with other staff confirmed that the expectation was to always clean from front to back to prevent contamination and infection. Record reviews for both residents indicated a history of significant medical conditions, including chronic kidney disease, neuromuscular dysfunction of the bladder, and a history of antibiotic-resistant urinary tract infection. Care plans and physician orders specified the need for catheter care every shift and the use of Catheter Holders to prevent trauma and infection. However, the care plans did not always address the presence of a Foley catheter, and the observed practices did not align with facility policy or physician orders. The facility was unable to provide a current catheter care policy upon request by the surveyor.
Failure to Develop and Initiate Discharge Plan for Medically Complex Resident
Penalty
Summary
The facility failed to ensure that the discharge needs of a resident were identified and that the discharge planning process resulted in the development of a discharge plan when a 30-day discharge notice was issued due to non-payment. The resident in question had a complex medical history, including coronary artery disease, diabetes mellitus, heart failure, COPD, peripheral vascular disease, hypertension, prior stroke, chronic kidney disease, anoxic encephalopathy, and was ventilator dependent with a tracheostomy and PEG tube. The resident was bedbound, in a persistent vegetative state, and required extensive care for multiple stage IV pressure ulcers. Despite these significant care needs, the facility did not initiate a discharge plan at the time the discharge notice was issued. Record review showed that the resident's care plan did not include a discharge plan, and the quarterly MDS assessment left the resident's overall goal blank, with no active discharge planning or referral to the Local Contact Agency. The responsible party for the resident had not paid the required applied income, leading to the issuance of the discharge notice. Facility staff, including the DON, ADONs, and Business Office Manager, reported that the social worker responsible for discharge planning had left the facility, and a replacement was not in place during the critical period. Attempts to contact the responsible party were limited to phone calls and emails, with no other methods used to facilitate discharge planning or ensure the resident's needs and preferences were addressed. Interviews with facility staff confirmed that no discharge plan was developed or initiated when the discharge notice was issued. The scheduled orientation for discharge planning was not conducted, and there was no documentation of efforts to coordinate a safe and appropriate discharge for the resident, who remained in a highly dependent state. The facility's own policy required assessment of continuing care needs and coordination of post-discharge services, but these steps were not taken in this case.
Failure to Employ Full-Time Social Worker and Complete Discharge Planning
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required for facilities with more than 120 beds. According to interviews and record reviews, the facility had not had a full-time social worker since December 11, 2025. The Director of Nursing (DON) and Administrator confirmed that the responsibilities of the social worker, including addressing grievances and initiating discharge plans, were being handled by themselves and Assistant Directors of Nursing (ADONs) in the absence of a social worker. The Administrator stated that although a new social worker was hired on November 24, 2025, this individual was terminated on December 11, 2025, and the position remained vacant at the time of the survey. A specific case involved a resident with complex medical needs, including a persistent vegetative state, ventilator dependence, multiple chronic conditions (such as CAD, DM, heart failure, COPD, PVD, HTN, prior CVA, CKD 3, and anoxic encephalopathy), and multiple stage IV pressure ulcers. The resident was bedbound, non-responsive, and required extensive care, including wound management, nutritional support, and mechanical ventilation. The resident's family desired all life-sustaining measures, and the care plan required ongoing monitoring and adjustment. Despite the issuance of a discharge notice due to non-payment, there was no active discharge planning or documentation of a discharge plan in the resident's care plan, and scheduled discharge planning orientation was not conducted as planned. Staff interviews revealed that grievances and discharge planning were not consistently managed according to facility policy during the period without a social worker. The DON and Administrator acknowledged lapses in grievance documentation and communication with families. The MDS nurses confirmed that the social worker would typically initiate interdisciplinary discharge planning, but this was not done for the resident in question. The facility was unable to provide a copy of the social worker job description when requested by the surveyor, and evidence of ongoing recruitment for the position was provided.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically by not implementing Enhanced Barrier Precautions (EBP) during high-contact care activities for a resident with a wound and indwelling medical devices. The resident in question had a history of frequent urinary tract infections, an indwelling Foley catheter, a feeding tube (G-tube), and a stage 2 pressure ulcer. The care plan and physician orders did not document the need for EBP, despite the resident's risk factors. Staff interviews confirmed that EBP training had been provided, and signage and personal protective equipment (PPE) were available near the resident's room. During direct observation, a nurse and a CNA entered the resident's room, failed to wash their hands, and did not don gowns or gloves before providing direct care, which included turning the resident and checking for skin breakdown. Both staff members acknowledged after the fact that they had been trained on EBP but failed to follow the protocol due to nervousness and being rushed. The CNA incorrectly believed EBP was no longer necessary because the resident's catheter had been discontinued, although the resident still had a G-tube and a pressure ulcer, which required continued EBP according to facility policy. Interviews with additional staff, including the DON and RN, confirmed that EBP should be followed for residents with indwelling medical devices or wounds during high-contact care activities. The facility's policy, effective as of April 2024, clearly outlined the requirements for EBP, including the use of gowns and gloves during specific care activities. Despite this, the observed failure to implement EBP placed the resident at risk for cross-contamination and the potential spread of infections.
Failure to Protect Residents from Abuse During Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure the right to be free from abuse for two residents, resulting in an incident where one resident physically assaulted another. On the date of the incident, a female resident with dementia, anxiety disorder, and impulse disorder, who had a history of wandering and required redirection, entered the room of a male resident with vascular dementia and severe cognitive impairment. The male resident, who had no prior history of physical aggression, was found by a staff member yelling for the other resident to leave his room. The staff member discovered the female resident in the male resident's room, with personal belongings scattered and water spilled on the floor. According to staff and documentation, the male resident hit the female resident in the face and threw items at her, resulting in immediate bruising to her face, knuckles, and shin. The female resident reported being hit, and a head-to-toe assessment confirmed the injuries. The incident was witnessed by a staff member, who intervened and removed the female resident from the room. Both residents were assessed for safety following the event. Prior to this incident, there were no documented altercations or aggressive behaviors between these two residents, and neither had exhibited physical or verbal aggression toward others according to their care plans and assessments. The facility's abuse and neglect policy required protection of residents from abuse by anyone, including other residents, and mandated prompt reporting and investigation of such incidents. However, the failure to prevent the altercation and protect the residents from abuse constituted a deficiency in upholding resident rights and safety.
Failure to Administer Correct Enteral Feeding Rate
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via a gastrostomy tube was provided with the correct feeding as ordered. The resident, who had a history of nutritional deficiency and protein-calorie malnutrition, was supposed to receive Isosource 1.5 at a rate of 50 ml/hr. However, the feeding pump was set to administer the formula at a continuous rate of 65 ml/hr, which was not in accordance with the updated order. This discrepancy was identified during an observation and interview, where the resident confirmed receiving all nutrition through the tube feeding without any issues. The Director of Nursing (DON) acknowledged the importance of following orders for patient care and admitted that a breakdown occurred when he did not follow up to ensure the feeding order change was implemented. The dietician had changed the order due to concerns about the resident's caloric intake and potential weight gain, but the change was not communicated effectively to the nursing staff. The resident's weight increased slightly from 146.2 lbs to 148.0 lbs during the period when the incorrect feeding rate was administered. Interviews with the primary care physician and the administrator highlighted the importance of adhering to feeding orders to ensure proper nutrition, although the physician noted that the feeding order discrepancy did not pose a health risk to the resident.
Failure to Maintain Accurate Resident Inventory Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the inventory of personal items. The resident, an elderly female with dementia and severely impaired cognition, had an inventory sheet that did not accurately document her belongings. The inventory sheet was marked as having no items of significant value, despite a grievance from a family member about a missing Christmas blanket. The Director of Nursing (DON) confirmed receiving a grievance about the blanket, which was later replaced by the facility. Interviews with facility staff revealed inconsistencies in the process of inventorying residents' personal items. The Medical Records/Central Supply staff indicated that items brought in by family or visitors should be declared and inventoried, but acknowledged that there would be no negative outcome if items were not inventoried. The Admission Coordinator noted that only three inventory sheets were available, with one being incomplete and unsigned. The facility's policy required items of sentimental value to be documented, but this was not adhered to, leading to the deficiency.
Failure to Include BiPAP in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident's use of a BiPAP machine. The resident, a cognitively intact female with a history of acute and chronic respiratory failure, chronic obstructive pulmonary disease, and dependence on supplemental oxygen, was admitted and readmitted to the facility. Despite having physician orders for nighttime use of a BiPAP machine to maintain oxygen saturation levels above 90%, the resident's care plan did not include this critical intervention. The care plan only addressed oxygen therapy without mentioning the BiPAP, even though the resident's oxygen saturation levels were consistently monitored and maintained as per the physician's orders. Interviews with the Director of Nursing (DON), MDS Coordinator, and the Administrator revealed that the omission of the BiPAP from the care plan was an oversight. The DON acknowledged that it was the responsibility of the nursing and MDS nurses to ensure care plans are updated and accurate, and admitted that the BiPAP should have been included. The MDS Coordinator explained that the resident was treated as a new admission upon readmission, and the BiPAP was not included in the care plan during the quarterly review. The Administrator confirmed that while the resident received the necessary services, the care plan did not reflect the use of the BiPAP, posing a risk of treatment not being provided if the care plan is not accurate.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, resulting in long and dirty fingernails. Resident #16, a male with dementia, hemiplegia, and major depressive disorder, was observed with long and dirty fingernails. He was dependent on staff for personal hygiene due to his medical conditions, including left-sided weakness from a cerebral infarction. Despite being scheduled for regular bathing, staff did not notice or address his nail care needs, leading to potential risks of skin tears and infection. Resident #17, a male with tracheostomy and gastrostomy status, also required substantial assistance with ADLs. He was cognitively intact but dependent on staff for personal hygiene. His fingernails were observed to be long and jagged, and he expressed concern about the risk of self-injury. The staff, including the Assistant Director of Nursing (ADON), acknowledged the oversight in nail care, which should have been performed as needed during bathing. Interviews with staff, including CNAs and the Regional Compliance Nurse, revealed a lack of awareness and communication regarding the residents' nail care needs. The facility's policy on nail care emphasized regular maintenance to prevent infection and injury, but this was not adhered to, resulting in the observed deficiencies. The Administrator confirmed the responsibility of CNAs, Med Aides, and nurses in ensuring proper nail care for residents dependent on staff assistance.
Failure to Label Enteral Feeding Bag
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. Specifically, the facility did not properly label the enteral feeding formula for a resident, which put the resident at risk of not receiving adequate nutrition. The resident, a male with a history of gastro-esophageal reflux disease, protein-calorie malnutrition, and gastronomy status, was observed to be on continuous g-tube feeding. During an observation, it was noted that the feeding bag was not labeled with the resident's name, date, and time it was hung, as required by the facility's policy. The Director of Nursing (DON) acknowledged that the feeding bag should have been labeled to ensure the proper feeding was administered and to monitor the feeding as ordered. The Licensed Vocational Nurse (LVN) responsible for the resident admitted to hanging the feeding bag without labeling it, stating he was interrupted by another resident. The LVN recognized the risk of administering the wrong feeding and the lack of monitoring due to the absence of labeling. The facility's gastronomy tube care policy requires that formula and feedings be labeled with at least the date and time the administration began.
Deficiency in Handling Advance Directives
Penalty
Summary
The deficiency involves the mishandling of advance directives, specifically Do Not Resuscitate (DNR) orders, for multiple residents. Resident #97 had a DNR request initiated by a social worker, but the document was pending a physician's signature, and there was no scanned DNR document in the electronic records. The compliance nursing team noted the need for a valid Texas Out-of-Hospital (OOH) DNR for in-house requests, but this was not completed. Similarly, for Resident #259, the OOH DNR was not signed by a physician, and the process was not completed. The facility began the enactment process for the DNR, but the document was scanned before the physician signed it, leading to an incomplete DNR status. The family had signed a request for DNR, but the necessary medical documentation was not finalized.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents were not given psychotropic drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for three residents who were reviewed for unnecessary medications. Resident #27 was administered Risperidone, an antipsychotic, to treat Delusional disorder, despite having no indicators of psychosis. The Director of Nursing (DON) expressed uncertainty about the appropriateness of the diagnosis for the use of an antipsychotic. Resident #93 was prescribed Aripiprazole, an antipsychotic, to treat depression, although his assessment showed no symptoms of delirium, depression, or psychosis. The DON acknowledged that prescribing an antipsychotic for depression was incorrect and highlighted the risks associated with such medications, including sleepiness and extrapyramidal effects. Resident #255 received Quetiapine, an antipsychotic, for dementia, despite having no symptoms of psychosis or behavioral symptoms. The DON confirmed that dementia was not an appropriate diagnosis for the use of Quetiapine and noted that it was the responsibility of the Assistant Director of Nursing (ADON) or the DON to contact the physician when a medication was prescribed with an incorrect indication.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Resident #155, who had Shingles, was placed under contact precautions instead of the required airborne and contact precautions. This oversight was confirmed by the Director of Nursing (DON), who acknowledged that the current precautions were incorrect and that the Shingles virus could potentially spread due to this error. The facility did not provide masks in the personal protective equipment (PPE) cart, and staff were observed entering the resident's room without masks, further compromising infection control measures. Additionally, the facility failed to ensure that urinary catheters for Residents #4, #33, and #73 were properly maintained off the floor, as required by their care plans. Observations revealed that the catheters were either dragging on the floor or improperly secured, increasing the risk of urinary tract infections (UTIs). Interviews with staff, including Licensed Vocational Nurses (LVNs) and the DON, highlighted a lack of adherence to the facility's policy on catheter care, which mandates that catheters be kept off the floor and in privacy bags. The DON admitted that approximately 20% of residents with catheters had UTIs, indicating a significant concern for infection control. The report also noted that the facility's staff, including CNAs, LVNs, and RNs, were responsible for monitoring catheter care but failed to consistently do so. The DON and other staff members acknowledged the potential risks associated with catheters being on the floor, such as contamination and injury to residents. Despite the facility's policy and the staff's awareness of the correct procedures, the lack of consistent implementation and monitoring led to the observed deficiencies in infection control practices.
Oxygen Machine Maintenance Deficiency
Penalty
Summary
The deficiency involves a failure to ensure that oxygen machines are functioning properly, specifically regarding the maintenance and checking of oxygen filters. The Director of Nursing (DON) was informed about the issue at 3:40 PM on July 25, 2024, highlighting that the responsibility lies with the respiratory therapist (RT) to ensure the oxygen machines are operating correctly. This oversight poses a risk to the resident, as it may result in the resident not receiving the desired effect of the oxygen, potentially leading to an increased risk of infection.
Failure to Assess and Document Use of Concave Mattress as Restraint
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints that were not required to treat medical symptoms, specifically concerning a concave mattress used for Resident 259. The resident, who was cognitively intact with a BIMS score of 14, had functional limitations in one arm and one leg and required assistance for mobility. Despite these needs, there was no documented assessment, physician's order, or consent for the use of a concave mattress, which was placed on her bed in early June. The resident expressed difficulty in getting out of bed due to the mattress's high sides, which she was told were intended to prevent falls. The Director of Nursing (DON) stated that an assessment was conducted to determine if the concave mattress was a restraint, concluding it was not because the resident could get out of bed without additional difficulty. However, the facility's policy required a physician's order and informed consent for any restraint, which was not obtained in this case. The facility's policy defined a physical restraint as any equipment that restricted freedom of movement and could not be easily removed by the resident, necessitating a physician's order and consent from the resident or responsible party.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not include interventions for the resident's urinary tract infection, shortness of breath, hypotension, impaired cognitive function, cellulitis, potential nutritional problem, mood problem, and depression. Additionally, the care plan for the resident's self-care deficit did not specify which areas of function, such as bed mobility, transfers, or toilet use, were to be maintained or improved. Interviews with facility staff revealed that the care plan was not personalized after the resident's admission, and there was no system in place for identifying incomplete care plans. The MDS Nurse indicated that the 5-day assessment should have triggered a review for inclusion in the comprehensive care plan, but this did not occur. The DON acknowledged that the care plan was not updated and that there was no routine for reviewing care plans to ensure completeness. This lack of a comprehensive care plan could result in the resident's care needs not being met.
Failure to Maintain Resident Nail Care
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and hygiene for two residents who were unable to perform activities of daily living independently. Specifically, the facility did not trim the fingernails of these residents, which was observed during a survey. Resident #26, who had a history of hypertension, cerebral infarction, and respiratory failure, required total assistance with ADLs and was unable to communicate effectively. During an observation, it was noted that Resident #26 had long fingernails, and interviews with staff revealed that nail care was supposed to be performed during showers, but this was not adequately done. Similarly, Resident #29, who also had a history of hypertension, cerebral infarction, and respiratory failure, was observed with long fingernails. This resident had severe cognitive impairment and difficulties in communication, making it challenging for him to express his needs or preferences regarding nail care. Staff interviews indicated that CNAs were responsible for the residents' hygiene, including nail care, but the necessary actions to maintain proper grooming were not consistently executed. The facility's policy on nail care, which includes regular cleansing, trimming, and smoothing of nails to prevent infection and injury, was not adhered to in these cases. The failure to maintain proper nail care for these residents placed them at risk of poor hygiene and potential health issues, as noted by the staff during interviews. The observations and interviews highlighted a deficiency in the facility's provision of personal hygiene services for residents who are unable to perform these tasks themselves.
Failure to Provide Adequate Range of Motion Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, identified as Resident #97, to maintain or improve her condition. Resident #97, who has moderate cognitive impairment and several medical diagnoses, was dependent on staff for various activities and had impairments in her range of motion in both arms and legs. Despite receiving some occupational and physical therapy, there was no recorded time for restorative therapy, and her care plan lacked specific interventions to address her range of motion issues. Interviews revealed that Resident #97 was discharged from physical and occupational therapy due to a change in her payer source, even though she had not met all her therapy goals. The Director of Rehabilitation acknowledged that the facility's restorative program had been discontinued months prior, and there was uncertainty about whether nurses were effectively monitoring residents for changes in functioning. The MDS Nurse and DON confirmed that changes in a resident's level of functioning would typically be identified through therapy assessments or reports from nursing staff, but there was no clear process in place following the suspension of the restorative program. The facility lacked policies and procedures regarding range of motion exercises and the restorative program, as confirmed by the DON. The Administrator mentioned that the restorative program was suspended, not discontinued, but the last time restorative staff worked was several months ago. This lack of structured support and monitoring for residents like Resident #97, who require ongoing therapy to prevent further decline, contributed to the deficiency identified in the report.
Deficiency in Resident Transfer Safety
Penalty
Summary
The facility failed to ensure adequate supervision and proper use of assistance devices for a resident, leading to a deficiency in accident prevention. The resident, who was at high risk for falls and had a history of paralysis following a stroke, was completely dependent on staff for transfers. Despite being identified as high risk, the resident experienced a fall when attempting to get out of bed, resulting in redness to the left arm. The incident highlighted the need for proper supervision and the use of appropriate safety measures, such as bed rails and low beds, to prevent accidents. During an observation, two aides were seen performing a mechanical lift transfer for the resident. The aides, one of whom was new to the facility, demonstrated improper techniques, including manually sliding the resident and jerking the lift over fall mats. The lift was lifted manually over the mats while the resident was unsecured, which posed a risk of injury. The Director of Nursing (DON) stated that the expectation was for transfers to be completed with two people, with the lift locked during the process, and that the staff had been trained on proper lift use. Interviews with staff revealed inconsistencies in training and understanding of proper mechanical lift procedures. The Physical Therapy Assistant (PTA) described the correct process, emphasizing the importance of locking the lift's brakes and using two staff members for transfers. However, the facility's in-service training and nurse aide checklist did not address specific issues such as jerking the lift over uneven surfaces. This lack of adherence to proper procedures and inadequate supervision contributed to the deficiency in ensuring resident safety during transfers.
Improper Handling of Urinary Catheter Bag
Penalty
Summary
A deficiency was identified involving the improper handling of a urinary catheter bag for a resident. On July 23, 2024, it was observed that the catheter bag was placed in a privacy bag but was resting on a fall mat, which is not in compliance with infection control protocols. An interview with a staff member confirmed that the catheter bag was touching the floor due to the fall mat, and it was acknowledged that the bag should not be on the floor for infection control reasons. On July 25, 2024, the Director of Nursing (DON) was questioned about the catheter bag being on the floor and admitted to not knowing the policy regarding whether the privacy bag provided sufficient protection. The DON recognized that if the privacy bag was not adequate, there was a risk of infection. It was noted that all clinical staff, including CNAs, are responsible for ensuring proper catheter care.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as observed during a survey. Resident #256, who had a history of stroke and was receiving oxygen therapy, was found with an oxygen concentrator filter that had accumulated dust. The resident's care plan lacked specific interventions for maintaining the oxygen equipment, and the staff responsible for the care of the oxygen filters did not ensure they were clean. This oversight increased the risk of the resident inhaling dust and germs, potentially compromising their oxygen absorption. Similarly, Resident #38, who had acute respiratory failure and was also on oxygen therapy, was observed with a dusty oxygen concentrator filter. Despite having a physician's order to clean or change the filter weekly, the filter was found with a dense accumulation of dust. Interviews with staff revealed a lack of clarity regarding the responsibility for maintaining the filters, which posed a risk of inadequate oxygen delivery and increased the potential for respiratory complications.
Deficiencies in Medication Administration and Storage
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications, as evidenced by the case of a resident who did not receive the prescribed multivitamin with minerals. The resident, who was admitted with diagnoses of nutritional deficiency and pressure ulcer, was given a multivitamin without minerals by LVN A, contrary to the physician's orders. LVN A admitted to not being sure if the correct multivitamin with minerals was available and later found it in the medication room, indicating a lapse in following the physician's order and ensuring the correct medication was administered. Additionally, the facility failed to manage medication storage properly, as observed with expired insulin pens found in two medication carts. Insulin pens in the carts for halls 400 and 500 were past their expiration dates, as indicated by the manufacturer's instructions. LVN A and LVN B, who were responsible for these carts, acknowledged that it was their responsibility to monitor and remove expired medications but failed to do so. This oversight could lead to residents receiving expired insulin, which may not provide the desired therapeutic effect. The Director of Nursing (DON) and the Administrator were informed of these deficiencies. Both acknowledged that the nursing staff should have followed the physician's orders and removed expired medications from the carts. The facility's pharmacy policy and procedure manual, which outlines the correct procedures for medication administration and storage, was not adhered to, contributing to these deficiencies.
Medication Administration and Storage Deficiencies
Penalty
Summary
The report identifies a deficiency related to medication administration and storage within the facility. During an interview and observation, an LVN admitted to administering a multivitamin without minerals to a resident, contrary to the physician's order for a multivitamin with minerals. The LVN was unsure if the correct vitamin was available and later found the appropriate vitamin in the medication room. The Director of Nursing (DON) and the Administrator acknowledged that the nurse should have followed the physician's order and reported the unavailability of the correct medication to ensure the resident received the intended treatment. Additionally, the report highlights issues with medication storage, specifically concerning expired insulin pens. During inspections of medication carts, it was found that some insulin pens were past their expiration date. The LVN acknowledged that it was the responsibility of each nurse to monitor and remove expired medications from the cart. The DON confirmed that insulin pens should be dated upon opening and are good for 28 days, and noted that expired insulins were not disposed of as expected. The Administrator also recognized the failure to remove expired insulins, which could result in residents not receiving the desired effect of the medication. The report includes multiple observations of medication carts and storage areas, noting that while controlled medications were properly accounted for, there were lapses in the management of regular medications, particularly with expired insulin pens. The facility's failure to ensure proper medication administration and storage practices led to the identified deficiencies, as staff did not adhere to established protocols for medication handling and reporting shortages.
Deficiency in DNR Documentation for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for three residents regarding their Do Not Resuscitate (DNR) status. For Resident #97, the facility documented a DNR status in the resident's chart without having a completed Texas Out of Hospital DNR form. The social worker indicated that the family had requested a DNR, and the facility considered the family member's signature on the DNR request as valid, even though the official document was pending a physician's signature. Resident #155 was listed as DNR in the facility's records, but there was no Out-of-Hospital DNR form present. The resident had verbally requested a DNR, which was documented and signed by two witnesses, but the necessary OOH-DNR form was not completed. The LVN noted that the electronic files showed the resident as DNR, but acknowledged the need for the actual form to validate the DNR status. For Resident #259, the facility documented a DNR status without a physician's signature on the Texas OOH DNR form. The social worker admitted to not noticing the missing signature and stated that the document was scanned into the system before the physician could sign it. The facility's policy was to treat residents as DNR once a request form was signed, even if the official OOH-DNR form was incomplete.
Failure to Address Grievance on Privacy Violation
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances, specifically for a resident whose family member raised concerns about privacy violations during perineal care. The resident, an elderly female with severe cognitive impairment and dependent on toileting, was observed on video footage receiving care from two CNAs with the privacy curtain open, exposing her to her roommate. The resident's representative reported this incident to the Weekend Supervisor and the Assistant Director of Nursing (ADON), but no formal grievance was initiated or documented. Interviews revealed that the Weekend Supervisor and ADON were aware of the privacy concern but did not follow the facility's grievance policy, which requires documentation and investigation of grievances. The Weekend Supervisor educated the CNAs on privacy but did not remember their identities, and the ADON verbally addressed the issue without initiating a grievance. The facility's Administrator acknowledged the lack of a grievance process, which resulted in no documentation or monitoring of the response to the family's concerns.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, resulting in inadequate personal hygiene care. Resident #19, a male with Parkinson's disease, tracheostomy, gastrostomy, and dependence on mechanical ventilation, was observed with long, jagged fingernails with dark discoloration. Despite being dependent on staff for personal hygiene, there was no record of when his nails were last trimmed, and the Licensed Vocational Nurse (LVN) was unaware of the last time the resident was bathed. Similarly, Resident #20, a male with tracheostomy, gastrostomy, and anxiety disorder, required maximum assistance with personal hygiene. He was found with long, jagged fingernails and expressed dissatisfaction with their length, indicating that staff should have been responsible for trimming them. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, revealed inconsistencies in the execution of nail care responsibilities. The ADON and DON acknowledged that nail care should be performed during bathing, but there was no clear timeframe for when this should occur. The facility's policy on nail care, dated 2003, emphasized regular and safe nail management to prevent infection and injury, yet this was not adhered to, as evidenced by the condition of the residents' nails. The lack of proper nail care could lead to poor care, lack of dignity, and potential skin tears for residents dependent on staff assistance.
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 could prevent the resident from having their needs met. The resident, a male with Parkinson's disease, tracheostomy status, gastrostomy status, and dependence on mechanical ventilation, was observed lying in bed with the call light tangled under the wheels of a monitor and out of reach. The resident was unable to communicate effectively due to a communication problem related to no speech and was rarely or never understood. The comprehensive care plan for the resident included ensuring the call light was within reach, but this was not adhered to during the observation. Interviews with facility staff, including a CNA, ADON, DON, and the Administrator, confirmed that it was the responsibility of all staff to ensure call lights were within reach of residents. The CNA acknowledged the call light was out of reach, and the ADON and DON emphasized the importance of call lights for residents to contact staff for assistance. The Administrator reiterated the expectation that call lights should be within reach and mentioned ongoing re-education efforts. Despite these acknowledgments, the deficiency was noted due to the failure to maintain the call light within the resident's reach, as required by the care plan.
Failure to Ensure Privacy During Personal Care
Penalty
Summary
The facility failed to ensure personal privacy during personal care for a resident, identified as Resident #22, by not closing the curtain while providing perineal care. This incident was observed in video footage where two CNAs were seen providing care with the curtain open, allowing the roommate to potentially view the care being given. The resident's responsible party (RP) had placed a video camera in the room and reported witnessing the incident to the Weekend Supervisor and ADON D. The resident, who was severely cognitively impaired and dependent on toileting, had a history of vascular dementia, cerebral infarction, and tracheostomy status. Interviews with the Weekend Supervisor, ADON D, and the Administrator revealed that the CNAs had been trained on providing privacy during care upon hire and as needed. However, the specific CNAs involved in the incident were not identified. The Weekend Supervisor and ADON D acknowledged the failure to close the curtain as a violation of the resident's privacy and dignity. The facility's Resident Rights policy emphasized the resident's right to personal privacy, which was not upheld in this instance.
Failure to Follow Care Plan for Resident Bathing Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident with multiple diagnoses, including dementia, seizures, schizophrenia, anxiety disorder, and moderate intellectual disability. The resident was dependent on staff for showering and required two-person assistance as per their comprehensive care plan. However, during an observation, a CNA was seen showering the resident alone, contrary to the care plan's requirements. The CNA admitted to bathing the resident alone due to pressure to complete showers, despite knowing the care plan required two-person assistance. The CNA acknowledged the risk of injury to the resident when not following the care plan. Interviews with the ADON, DON, and Administrator confirmed that the care plan should be followed for safety reasons and that staff are trained to refer to the Kardek for assistance requirements. The facility's policies on bathing and comprehensive care planning emphasize the need for staff to be familiar with the type and pattern of assistance required for each resident. The failure to adhere to the care plan placed the resident at risk of not receiving necessary care and services, potentially leading to accidents or harm.
Failure to Replace Contaminated Tracheostomy Tubing
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, specifically by not replacing the tracheostomy ventilation circuit tubing that contained red/brownish particles for two days. The resident, an elderly female with vascular dementia, cerebral infarction, and tracheostomy status, was observed on two separate occasions with the contaminated tubing. Despite the presence of these particles, the resident showed no signs of distress and was non-verbal. Interviews with the respiratory therapist (RT) and the Director of Nursing (DON) revealed a lack of adherence to the facility's protocol for maintaining clean tracheostomy equipment. The RT, who was responsible for the resident's care, admitted to not noticing the particles and stated that the equipment was replaced weekly. The DON confirmed that the nursing department was responsible for ensuring the cleanliness of the equipment and that RTs should check and replace equipment as needed. The failure to replace the contaminated tubing placed the resident at risk of infection.
Failure to Provide Adequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure that Resident #10 received adequate supervision and assistance devices to prevent accidents. On 3/7/24, CNA G provided perineal care to Resident #10, who required two-person assistance, without asking for help. During the care, Resident #10 started coughing and rolled off the bed, resulting in a fall and a laceration above her right eyebrow. This incident was documented by LVN F and ADON D, who both confirmed that Resident #10 required two-person assistance for perineal care, which CNA G failed to obtain. Resident #10, a [AGE] year-old female with severe cognitive impairment, muscle weakness, and tracheostomy status, was dependent on staff for toileting and required two-person assistance for incontinent care as per her care plan and Kardex. On the day of the incident, CNA G, despite being aware of the requirement for two-person assistance, chose to perform the task alone, leading to the resident's fall and subsequent injury. The resident was assessed on the floor, and emergency services were called to transport her to the hospital, where she received treatment for her laceration. Interviews with the involved staff revealed that CNA G was aware of the need for two-person assistance but failed to ask for help, believing it would be easier to perform the care alone. This lapse in following the care plan directly resulted in the resident's fall and injury. The facility had already implemented corrective actions before the surveyor's investigation began, but the incident highlighted a significant lapse in adherence to care protocols, which could place residents at risk of accidents and potential harm.
Failure to Provide Proper Catheter Care
Penalty
Summary
The facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for two residents reviewed for urinary catheter care. Specifically, Resident #9's urinary catheter was observed placed on top of the bed without a privacy bag, and during the process of emptying the catheter, urine spilled on the floor, which was cleaned with adult wipes that do not have disinfectant agents. CNA A admitted to not following proper procedures due to nervousness from being observed, which was confirmed by ADON D who stated that CNAs are trained to empty urine below the bladder to prevent backflow and spillage, and that failure to do so could lead to cross-contamination and infection. Resident #9 had diagnoses including quadriplegia, tracheostomy, muscle wasting, and anxiety, and required 2-person assistance with bed mobility and toileting, with an intact cognition as per his MDS assessment dated 4/1/24. The facility's failure to follow proper catheter care procedures placed Resident #9 at risk of infection. Additionally, the facility failed to provide catheter care for Resident #4 every shift as required. Resident #4, a male diagnosed with sepsis, urinary tract infection, and mechanical complication of urinary catheter, had a care plan that included providing catheter care every shift. However, records showed multiple instances where catheter care was not provided on various dates across several months. The DON confirmed that catheter care should be provided every shift as indicated and acknowledged that failure to do so could result in a risk for infection. The facility's catheter care policy emphasized keeping the drainage bag below the level of the bladder, but this was not consistently followed for Resident #4, leading to potential risks of infection.
Infection Control and Perineal Care Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which led to deficiencies in the care of two residents. One resident, who was COVID-19 positive, was not recorded in the Infection Control Log, which is essential for surveillance and monitoring of outbreaks. The Director of Nursing (DON), who is also the Infection Preventionist, acknowledged that the resident's COVID-19 status should have been documented to prevent the spread of infection and to comply with the facility's infection control plan. The failure to document this case in the Infection Control Log was a significant oversight in the facility's infection control practices. Another deficiency was observed during the provision of perineal care to a resident. A Certified Nursing Assistant (CNA) failed to change gloves after cleaning the resident's bowel movement (BM) and continued to provide activities of daily living (ADL) assistance with the same dirty gloves. This included applying lotion, fixing bed sheets, and adjusting the resident's tracheostomy tube. The CNA admitted that she should have changed gloves to prevent cross-contamination and reduce the risk of infection. The Assistant Director of Nursing (ADON) confirmed that CNAs are trained to change gloves after handling soiled briefs to prevent cross-contamination. The facility's policies on infection control and bowel incontinence care were not followed, leading to these deficiencies. The Infection Control Plan requires maintaining records of infections and performing surveillance to prevent the spread of disease. The Bowel Incontinence Care policy mandates the disposal of soiled briefs using universal precautions, but it did not specify the need to change gloves after handling soiled briefs. These lapses in following established protocols placed residents at risk for infection and highlighted gaps in the facility's infection control practices.
Failure to Document Physician Orders for Covid-19 Isolation
Penalty
Summary
The facility failed to ensure that medical records for Resident #7 were complete and accurately documented. Specifically, there were no physician orders for Resident #7, who was Covid-19 positive on 01/31/24 and placed in isolation. The resident's care plan required isolation precautions due to an active Covid-19 infection, but the necessary physician orders were not documented. This oversight was confirmed during interviews with LVN C and the Director of Nursing (DON), who both acknowledged the absence of physician orders for the isolation. Resident #7, a [AGE] year-old female with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was re-admitted to the facility on 01/11/24. The resident's care plan included specific instructions for managing her Covid-19 infection, such as isolation, fluid intake, and oxygen availability. Despite these detailed care instructions, the facility did not have the required physician orders for the isolation, as confirmed by the DON. Additionally, a request for the facility's Physician Orders policy was not fulfilled by the Administrator, further highlighting the deficiency in documentation and procedural adherence.
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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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